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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880741
Report Date: 05/04/2022
Date Signed: 05/04/2022 02:49:31 PM


Document Has Been Signed on 05/04/2022 02:49 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:ARLINGTON RIVERSIDE SENIOR COMMUNITYFACILITY NUMBER:
331880741
ADMINISTRATOR:KURT NIEBRESFACILITY TYPE:
740
ADDRESS:4609 ARLINGTON AVETELEPHONE:
(951) 462-1025
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY:150CENSUS: 63DATE:
05/04/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Kurt Niebres, AdministratorTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to initiate the investigation into complaint #18-AS-20220503112715. During the investigation the below violation was observed.

During an interview, Staff One (S1) reported not having conducted all of the requirements listed in 1569.69(a)(4)(A) through (I). When asked if the facility provided training on any of the items in 1569.69(a)(4)(A) through (I) S1 stated they only received a briefing from the previous Wellness Director and not a formal training. S1 reported not having signed any training documentation or certificates. S1 also reported not having had to undergo an examination that tests their comprehension of, and competency in, the subjects listed in paragraph(4). In addition, the LPA and Administrator together reviewed S1's file. No observation was made of the proof of the training of S1 in each of the subject matters listed in paragraph (4) nor any proof of the passing of an examination on the subject matters listed in paragraph (4). Per S1, they have been administering medication since February 2022. This poses an immediate threat to the health and safety of the residents in care. A citation will be issued.

An exit interview was conducted; this report was reviewed with Niebres, and a copy was provided.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/04/2022 02:49 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: ARLINGTON RIVERSIDE SENIOR COMMUNITY
FACILITY NUMBER: 331880741

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/04/2022
Section Cited

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EMPLOYEES ASSISTING RESIDENTS WITH SELF-ADMINISTRATION OF MEDICATION; TRAINING REQUIREMENTS : Each RCFE licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training
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requirements: The training shall cover all of the following areas...This requirement was not met, as evidenced by: Based on interview and records review, the Licensee did not ensure S1 was trained in the required subject matters prior to conducting medication administration.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2022
LIC809 (FAS) - (06/04)
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