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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 09/17/2021
Date Signed: 09/17/2021 02:22:31 PM

Unsubstantiated


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
02/14/2020 and conducted by Evaluator Jennifer Semin
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200214092837
FACILITY NAME:ARLINGTON RIVERSIDE SENIOR COMMUNITYFACILITY NUMBER:
331880741
ADMINISTRATOR:HIGGINS, DEBORAHFACILITY TYPE:
740
ADDRESS:4609 ARLINGTON AVETELEPHONE:
(714) 476-7777
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY:150CENSUS: 51DATE:
09/17/2021
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Kurt NiebresTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Facility staff are not providing resident with clean linens on a regular basis
Resident's room is malodorous
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jennifer Semin conducted an unannounced visit to deliver the findings for the above complaint allegations. LPA met with administrator Kurt Niebres.
Regarding the first allegation, Facility staff are not providing resident with clean linens on a regular basis. Resident 1 (R1) could not recall how often bedding is changed but recalls it being laundered often. Staff stated bedding is changed at least weekly and more often as needed. LPA observed R1’s linens to be clean.
Regarding the second allegation, Resident's room is malodorous. R1 has not noticed their room being malodorous. Staff stated they clean R1’s room daily. LPA did not observe R1’s room to be malodorus.
Based upon interviews and information gathered, and although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED at this time.

An exit interview was conducted where this report was discussed and provided to administrator.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Jennifer SeminTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021
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 3
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
02/14/2020 and conducted by Evaluator Jennifer Semin
COMPLAINT CONTROL NUMBER: 18-AS-20200214092837

FACILITY NAME:ARLINGTON RIVERSIDE SENIOR COMMUNITYFACILITY NUMBER:
331880741
ADMINISTRATOR:HIGGINS, DEBORAHFACILITY TYPE:
740
ADDRESS:4609 ARLINGTON AVETELEPHONE:
(714) 476-7777
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY:150CENSUS: 51DATE:
09/17/2021
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Kurt NiebresTIME COMPLETED:
02:45 PM
ALLEGATION(S):
1
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9
Facility staff left resident in soiled clothing for an extended period of time
Resident sustained multiple falls while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jennifer Semin conducted an unannounced visit to deliver the findings for the above complaint allegations. LPA met with administrator Kurt Niebres.
Regarding the first allegation, Facility staff left resident in soiled clothing for an extended period of time. Resident 1 (R1) stated staff do not do rounds regularly and often R1 remains in soiled clothing waiting for staff assistance. Staff deny leaving R1 in soiled clothing but could not produce a schedule for R1’s monitoring. Regarding the second allegation, Resident sustained multiple falls while in care. R1 stated when staff continually do not come to R1’s room for assistance, R1 stated after several unanswered calls, R1 will attempt to get out of bed unassisted resulting in falls. Staff deny not assisting R1, that R1’s fall are not due to lack of supervision. LPA observed multiple special incident reports indicating R1 fell while trying to transition from R1’s wheelchair to bed or vise versa when alone in their room. Based on documentation and interviews, which were conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. An exit interview was conducted where a copy of this report (LIC9099 and LIC 9099-D) and appeal rights were provided to administrator.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Jennifer SeminTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021
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 3
Control Number 18-AS-20200214092837
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: 09/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/18/2021
Section Cited
CCR
87464(f)(4)
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Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications, as specified in
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Licesnee shall read this regulation in it's entirety, conduct staff training and submit a statement of understanding ajnd training log to CCL nby the POC due date of 9/18/2021.
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Section 87608, Postural Supports.
This requirement was not met as evidence by: R1 remains in soiled clothing waiting for staff assistance. This poses a serious health and safety risk to residents in care.
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Type A
09/18/2021
Section Cited
CCR
87468.2(a)(4)
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In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights. To care, superviion and services that meet their individual needs
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Licesnee shall read this regulation in it's entirety, conduct staff training and submit a statement of understanding ajnd training log to CCL nby the POC due date of 9/18/2021.
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and are delivered by staff that are sufficient in numbers, qualifications, & competency to meet their needs. This requirement was not met as evidence by: R1 sustained multiple falls due to staff not assisting R1 as needed. This poses a serious health and safety risk to residents in care.
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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: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Jennifer SeminTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3