<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 03/01/2022
Date Signed: 03/01/2022 01:48:59 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
12/21/2020 and conducted by Evaluator Stephanie Torres
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20201221120138
FACILITY NAME:ARLINGTON RIVERSIDE SENIOR COMMUNITYFACILITY NUMBER:
331880741
ADMINISTRATOR:GEMMA DEOSOFACILITY TYPE:
740
ADDRESS:4609 ARLINGTON AVETELEPHONE:
(951) 462-1025
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY:150CENSUS: 65DATE:
03/01/2022
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Kurt Niebres, AdministratorTIME COMPLETED:
01:50 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff are not responding to resident's call button.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to deliver the findings of the investigation into the above allegations. The LPA met with Administrator, Kurt Niebres, and informed him of the purpose of the visit.

Pertaining to the allegation, "Facility staff are not responding to resident's call button," it was alleged that staff members are not responding to resident's call buttons in a timely manner. The investigation was initiated on December 22, 2020. Staff/resident interviews were conducted; four (4) of the eleven (11) interviews conducted reported facility staff take a long time to respond to the facility call system. A Situational Awareness and Response Assistant (SARA) log was obtained for December 21, 2020. The record shows fifteen (15) calls were made for staff assistance and were not answered for more than thirty (30) minutes. Two (2) interviews reported staff assistance was needed to utilize the restroom, however, was not provided in a timely manner. This posed a potential threat to the health, safety, and personal rights of the residents in care. Therefore, this allegation is
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 295-3927
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
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
12/21/2020 and conducted by Evaluator Stephanie Torres
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20201221120138

FACILITY NAME:ARLINGTON RIVERSIDE SENIOR COMMUNITYFACILITY NUMBER:
331880741
ADMINISTRATOR:GEMMA DEOSOFACILITY TYPE:
740
ADDRESS:4609 ARLINGTON AVETELEPHONE:
(951) 462-1025
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY:150CENSUS: 65DATE:
03/01/2022
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Kurt Niebres, AdministratorTIME COMPLETED:
01:50 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident left on toilet for extended period of time resulting in legs going numb.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to deliver the findings of the investigation into the above allegations. The LPA met with Administrator, Kurt Niebres, and informed him of the purpose of the visit.

With regard to the allegation, "Resident left on toilet for extended period of time resulting in legs going numb," it was alleged a resident in care was utilizing the toilet, on or around December 21, 2020, and facility staff did not respond in a sufficient amount of time, resulting in the resident's legs going numb. Staff/resident interviews were conducted; one (1) of the eleven (11) interviews conducted reported one resident has been left on the toilet for an extended period of time. This individual, Resident One (R1), was interviewed and could not recall if their legs became numb or not. Therefore, due to insufficient information, this allegation is deemed UNSUBSTANTIATED at this time. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. This report was reviewed with Administrator Niebres and a copy was provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 18-AS-20201221120138
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: 03/01/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
deemed SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

An exit interview was conducted; this report was reviewed with Administrator Niebres and a copy was provided, along Appeal Rights
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 18-AS-20201221120138
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: 03/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/15/2022
Section Cited
CCR
87411(a)
1
2
3
4
5
6
7
PERSONNEL REQUIREMENTS-GENERAL: Facility personnel shall at all times be sufficient in numbers, & competent to provide the services necessary to meet resident needs...This requirement wasn't met, as evidenced by: Based on records & interviews, the Licensee didn't ensure personnel were
1
2
3
4
5
6
7
Administrator Niebres stated in-service training will be provided to all care staff regarding answering the call system in a timely manner.
8
9
10
11
12
13
14
sufficient in numbers to meet needs. Interviews reported staff take a long time to respond to the call system. A SARA log showed 15 calls were made & not answered for more than 30 min. 2 interviews reported assistance was needed to use the restroom & was not provided in a timely manner.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 03/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4