331880741-9-19-2022-18-AS-DMUN-CK7UWV-20221014155719

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 09/19/2022
Date Signed: 09/19/2022 04:31:05 PM

Substantiated

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
09/16/2022 and conducted by Evaluator Stephanie Torres

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20220916151753

FACILITY NAME:	ARLINGTON RIVERSIDE SENIOR COMMUNITY		FACILITY NUMBER:	331880741
ADMINISTRATOR:	KURT NIEBRES		FACILITY TYPE:	740
ADDRESS:	4609 ARLINGTON AVE		TELEPHONE:	(951) 462-1025
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92504
CAPACITY:	150	CENSUS: 72	DATE:	09/19/2022
		UNANNOUNCED	TIME BEGAN:	12:39 PM
MET WITH:	Kurt Niebres, Administrator		TIME COMPLETED:	04:40 PM

ALLEGATION(S):

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Facility personnel lacked competence to meet resident needs

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to initiate the investigation into the above allegation. The LPA met with Administrator, Kurt Niebres, and informed him of the purpose of her visit.

During this visit, the LPA conducted staff interviews, reviewed records, and obtained copies of pertinent documentation. Regarding the allegation, "Facility personnel lacked competence to meet resident needs," it was alleged Staff One (S1), with their partner, arrived at the facility and assaulted Staff Two (S2) on September 16, 2022. Staff interviews were conducted; it was reported S1 left the facility, on September 16, 2022, after their shift, returned approximately a half hour later, with an unknown individual, and assualted S2 in the medication room. Interviews reported S1 and S2 had a verbal altercation and S1 threatened to bring their partner to the facility to assault S2. It was reported S1 entered into the facility through a side door, searched and found S2, and called their partner into the room. Witnesses reported S1's partner punched and kicked S2. In addition, it

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2022

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-20220916151753

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: 09/19/2022

NARRATIVE

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was reported S1 kicked S2 two (2) times and poured water on the staff member. S1 and their partner reportedly left the facility immediately after the assault commenced. This poses a potential threat to the health, safety and personal rights of the residents in care. Therefore, based on interviews, this allegation is deemed SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

A citation and civil penalty (due to a repeat violation) will be issued. An exit interview with Niebres was conducted; this report was reviewed and a copy, along with LIC 811, LIC 421FC, and Appeal Rights were provided.

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2022

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20220916151753

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: 09/19/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/26/2022 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	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 was not met, as evidenced by: Based on interviews	1 2 3 4 5 6 7	S1 was terminated on 09/16/22. The Administrator agreed that an in-service training with all staff will be held to discuss facility procedures when disagreements take place between staff members.
	8 9 10 11 12 13 14	the licensee did not ensure facility personnel was competent. Interviews reported S1 left the facility, on 09/16/22, after their shift, returned approximately a half hour later, with an unknown individual, & assualted S2 in the med. room.	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: Deborah Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2022

LIC9099 (FAS) - (06/04)

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