331880741-4-19-2022-18-AS-NBRN-CEPURG-20220523154844

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 04/19/2022
Date Signed: 04/19/2022 07:18:54 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/12/2021 and conducted by Evaluator Amy Goldenberg

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20210412121732

FACILITY NAME:	ARLINGTON RIVERSIDE SENIOR COMMUNITY		FACILITY NUMBER:	331880741
ADMINISTRATOR:	GEMMA DEOSO		FACILITY TYPE:	740
ADDRESS:	4609 ARLINGTON AVE		TELEPHONE:	(951) 462-1025
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92504
CAPACITY:	150	CENSUS: 64	DATE:	04/19/2022
		UNANNOUNCED	TIME BEGAN:	05:15 PM
MET WITH:	Kurt Niebres Administrator		TIME COMPLETED:	08:00 PM

ALLEGATION(S):

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-Staff do not have access to resident's medical files
-Staff did not provide access for fire dept in a timely manner

INVESTIGATION FINDINGS:

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Licensing program Analyst (LPA) Amy Goldenberg is conducting this unannounced visit to conclude the investigation of the above noted alleged violations.

During the course of the investigation information was obtained through interviews with Emergency Medical Services (EMS), Administrator Gemma Deosso, and night shift caregiver (S1). LPA learned the following information: When requested the facility staff could not produce evidence of the availibility of resident information for EMS. EMS could not gain access to the facility on 4/11/2021 after ringing the doorbell.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy Goldenberg	TELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20210412121732

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 04/19/2022

NARRATIVE

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Emergency responders called out to staff for entry and no one was responding. Staff eventually arrived and reported that the facility pager was broken. EMS again rang the front doorbell and became aware that the pager was ringing and functional. It is reported that only one staff was present. Interview of facility administrator revealed that there was only one staff for medication and care giving on the night of the incident. Interview with the caregiver (S1) confirms that they are often alone on their shift.

We have substantiated the complaint allegations as valid and that a violation has occurred based on the preponderance of available evidence. A copy of this report along with appeal rights are being reviewed with, and furnished to the facility representative. Please see LIC 9099D.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy Goldenberg	TELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 18-AS-20210412121732

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/19/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/20/2022 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet residents needs. The facility failed to meet this requirement as	1 2 3 4 5 6 7	Licensee to ensure there is adequate staffing at night to ensure resident safety. All night staff to be retrained on responding
	8 9 10 11 12 13 14	evidenced by information received during interviews indicating one staff was present on 4/11/2021 resulting in failure to ensure EMS access during an emergency.	8 9 10 11 12 13 14	Please provide supporting documentation of night shift training once completed. ** A Civil Penalty assessment accompanies the deficiency for repeated violation.
Type A 04/20/2022 Section Cited CCR 87415(a)	1 2 3 4 5 6 7	...persons providing night supervision from l0:00 p.m. to 6:00 a.m. shall be familiar with the facility's planned emergency procedures....shall be available... to assist in caring for residents in the event of an emergency.	1 2 3 4 5 6 7	All night staff to be trained on the regulation section cited. Please provide supporting documentation of night shift training once completed.
	8 9 10 11 12 13 14	The facility failed to meet this requirement as evidenced by inability of night staff to assist in caring for residents in the event of an emergency when they were unable to provide EMS with resident information.	8 9 10 11 12 13 14

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: Nedra Brown	TELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy Goldenberg	TELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022

LIC9099 (FAS) - (06/04)

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