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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880741
Report Date: 09/01/2022
Date Signed: 09/01/2022 03:07:48 PM


Document Has Been Signed on 09/01/2022 03:07 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:
09/01/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:43 PM
MET WITH:Kurt Niebres, AdministratorTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to address concerns observed during a case management visit on August 31, 2022. The LPA met with Administrator, Kurt Niebres, and informed him of the purpose of the visit.

The LPA observed insufficient staffing during a visit on August 31, 2022; the LPA observed only one staff present; one resident was observed to be calling out for assistance and reported they had been been waiting for several hours, interview revealed Staff One (S1) was conducting multiple tasks, such as passing out medications, changing residents, putting residents to sleep, and checking on residents routinely. In addition, the LPA observed the call system, which transmits a visual signal to a centrally staffed location, was not monitored appropriately. The LPA observed insufficient staff available to monitor the visual signal sent to the medication room. This poses an immediate risk to the health and safety of the residents in care. A Citation and Civil Penalty (due to a repeat violation) will be issued.

An exit interview was conducted; this report was reviewed with Niebres and a copy was provided, along with the LIC 811, LIC 421FC, and Appeal Rights.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2022
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 09/01/2022 03:07 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: 09/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/01/2022
Section Cited

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PERSONNEL REQUIREMENTS - GENERAL: (a) 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 interview & observation, the Licensee didn't ensure staffing was
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sufficient. The LPA observed insufficient staffing on 08/31/22; only 1 staff was present; 1 resident was observed to be calling for assistance, S1 was conducting multiple tasks, the LPA observed the call system not to monitored appropriately.
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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: 09/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2022
LIC809 (FAS) - (06/04)
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