331880741-2-23-2021-18-AS-NBRN-BYLUHP-20210226143612

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 02/23/2021
Date Signed: 02/23/2021 10:57:04 AM

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
06/02/2020 and conducted by Evaluator Amy Goldenberg

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200602141522

FACILITY NAME:	ARLINGTON RIVERSIDE SENIOR COMMUNITY		FACILITY NUMBER:	331880741
ADMINISTRATOR:	HIGGINS, DEBORAH		FACILITY TYPE:	740
ADDRESS:	4609 ARLINGTON AVE		TELEPHONE:	(951) 462-1025
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92504
CAPACITY:	150	CENSUS: 63	DATE:	02/23/2021
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Gemma Deoso, Administrator		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Facility dishes are not properly cleaned

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Amy Goldenberg is conducting a visit to conclude this agency's investigation into the complaint allegations noted above. LPA met with Gemma Deoso, Administrator and discussed the findings of the investigation conducted and written by LPA Susan Parker below.

"The allegation consisted of the following: LPA Parker interviewed residents #1, 2, 3, 4, 5, 6 and #7, staff #1, former administrator Deborah Higgins, and LPA Parker received a copy of a receipt for repair of the dishwasher.

The investigation revealed the following: Former administrator Deborah Higgins told LPA that in early June 2020 the purifier tank on the dishwasher stopped working.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy Goldenberg	TELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20200602141522

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: 02/23/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/25/2021 Section Cited CCR 87555(b)29	1 2 3 4 5 6 7	GENERAL FOOD SERVICE REQUIREMENTS (b)(29) All equipment, fixed or mobile, and dishes, shall be kept clean and maintained in good repair and free of breaks, open seams, cracks or chips.	1 2 3 4 5 6 7	Per former administrator, the purifier tank was replaced on 6/5/20. Deficiency was corrected.
	8 9 10 11 12 13 14	This requirement was not met as evicenced by: Based on staff interview, licensee failed to ensure dishes were kept clean from food debris which poses a potential health risk.	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: Nedra Brown	TELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy Goldenberg	TELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2021

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20200602141522

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: 02/23/2021

NARRATIVE

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Ms. Higgins said as soon as it was brought to her attention, she put in an order to have the purifier tank replaced. During the time the tank was not working, Ms. Higgins said the residents were served their meals on paper plates. A few of the residents whom LPA interviewed said they did see old food on their plates. Ms. Higgins told LPA the purifier tank was replaced on 6/5/20.

The purifier tank on the dishwasher did stop working which resulted in old food being stuck to the dishes. Based on this fact and resident and staff interviews, the preponderance of evidence standard has been met......therefore the allegation is substantiated.

California Code of Regulations, Title 22, Division 6, Chapter 8 is cited on the attached LIC 9099D."

LPA Goldenberg reviewed this report and appeal rights with the facility representative, Gemma Deoso and copies were provided during the exit interview.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy Goldenberg	TELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2021

LIC9099 (FAS) - (06/04)

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