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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880741
Report Date: 08/31/2022
Date Signed: 08/31/2022 09:21:51 PM


Document Has Been Signed on 08/31/2022 09:21 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: 73DATE:
08/31/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:00 PM
MET WITH:Jenesa McDonald, Business Office ManagerTIME COMPLETED:
09:30 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-20220826134748. The LPA met with Staff, Lydia Unabia, and informed her of the purpose of the visit. Business Office Manager (BOM), Jenesa McDonald, arrived during the visit.

The LPA toured the facility and conducted staff interviews. Upon arrival the LPA was informed by residents in care there was only one staff, Staff One (S1), who was present at the time. S1 was interviewed and confirmed they were the only staff present at the time. S1 stated they were conducting multiple tasks at this time, such as passing out medications, changing residents, putting residents to sleep, and checking on residents routinely. S1 was asked how they monitor the call system at the facility, to which they stated they check on residents room by room. S1 also stated they check the monitor for the call system, however, the LPA observed the computer to be asleep and no system to be open when the staff opened the screen.

In addition, the LPA observed Resident One (R1) to be yelling for help. When the LPA checked on the resident they reported they had not been checked on for several hours. R1 reported they needed to be turned and have their adult diaper changed.

S1 reported they had contacted Administrator, Kurt Niebres, and BOM, Jenesa McDonald, to inform them there were no additional staff available. Staff Two (S2) and Staff Three (S3) were observed to arrive during the visit.

The LPA will follow up with the Licensee to address concerns observed at time of visit, in order to obtain further information. This report was reviewed with McDonald 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: 08/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2022
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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