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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880741
Report Date: 09/23/2022
Date Signed: 09/23/2022 02:02:17 PM


Document Has Been Signed on 09/23/2022 02:02 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: 72DATE:
09/23/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Jenesa McDonald, Business Office ManagerTIME COMPLETED:
02:10 PM
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Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to follow up on the Plan of Correction for a citation issued, regarding complaint #18-AS-20220909110427. The LPA met with Jenesa McDonald, Business Office Manager (BOM) and informed her of the purpose of her visit.

On September 09, 2022, the LPA substantiated a complaint alleging the facility failed to repair the air conditioning (AC) unit servicing the bedroom of Resident One (R1) and Two (R2). The Plan of Correction (POC), agreed upon by Administrator Niebres, was to have the unit repaired and a statement of certification would be submitted by September 16, 2022. According to maintenance staff the AC unit has yet to be fully repaired. It was reported a company visited the facility today (09/23/22) to service the unit, however, a return visit is needed next week to continue the work.

The Department has not received a request to extend the due date of the POC from the facility. A civil penalty will be issued due to a failure to correct the violation.

An exit interview was conducted 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: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2022
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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