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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 03/26/2022
Date Signed: 03/26/2022 03:55:40 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
11/06/2020 and conducted by Evaluator Amy Goldenberg
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20201106100804
FACILITY NAME:ARLINGTON RIVERSIDE SENIOR COMMUNITYFACILITY NUMBER:
331880741
ADMINISTRATOR:GEMMA DEOSOFACILITY TYPE:
740
ADDRESS:4609 ARLINGTON AVETELEPHONE:
(951) 462-1025
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY:150CENSUS: 60DATE:
03/26/2022
UNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Jenesa McDonald, Business Office ManagerTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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-Facility staff did not assist resident with changing colostomy bag in a timely manner
-Resident was left in soiled clothing for an extended period of time
-Facility staff withheld food from resident
-Facility staff are not dispensing medication as prescribed

INVESTIGATION FINDINGS:
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This unannounced visit conducted by Amy Goldenberg, Licensing Program Analyst (LPA), is being conducted to conclude the investigation of the above-mentioned complaint allegations.

During the course of the investigation LPA interviewed six (6) residents. LPA learned the following information: Six (6) out of six (6) residents interviewed report that the staff do not respond to the call bell in a timely manner, and that wait times can be extensive, as long as 3 hours. It is alleged that staff did not assist R1 with changing their colostomy bag in a timely manner and that resident was left soiled from 0600 until 1400. Based on interviews it is reasonable to believe that the allegations happened as reported. It is alleged that no one brought R1 their breakfast or lunch several times.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 18-AS-20201106100804
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: 03/26/2022
NARRATIVE
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Five (5) out of six (6) residents interviewed have expressed that their preferences in the food being served was not being met but do not state that their food was being withheld. It has been determined that staff are not responding to residents care needs and that R1 was left for several hours in their soiled clothing without assistance. It is reasonable to believe that during this time that likewise, their food was not delivered to their room. It is alleged that facility staff are not dispensing medications as prescribed. On this date LPA found a small yellow pill on the floor in the hallway verifying that medications are not being handled and dispensed properly.

We have substantiated the complaint allegations are valid and that violations have occurred based on the preponderance of available evidence. A copy of this report along with appeal rights are being reviewed with, and furnished to the facility representative. Please see LIC 9099D.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 18-AS-20201106100804
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: 03/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/28/2022
Section Cited
CCR
87468.2(a)(4)
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Personal Rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
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Licensee to review and provide a written statement of understanding regarding the regulation section cited by POC due date along with plan to ensure staffing is maintained in such a manner as to be able to meet all the needs of the residents in care.
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The facility failed to meet this requirement as evidenced by insufficient staffing resulting in R1 being left in soiled clothing and without food from 0600 until 1400. This poses a risk to their health and safety while in care.
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Type A
03/28/2022
Section Cited
CCR
87465(h)(2)
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Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.The facility has failed
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Licensee to review regulation section cited and provide a statement of understanding to CCL by POC due date. Training to additionally occur for all employees handling resident medications.
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to meet this requirement as evidenced by the following: LPA found a small yellow pill on the floor in the hallway accessible to others in care. This poses a risk to the health and safety of residents in care.
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Training should focus the steps of verifying medications prior to dispensing of medications to ensure all medications are dispensed and taken as ordered.
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 BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 18-AS-20201106100804
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: 03/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/28/2022
Section Cited
CCR
87555(a)
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The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents...The facility has failed to meet this requirement as evidenced by R1 not receiving their meals on
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Licensee to review and provide a written statement of understanding regarding the regulation section cited by POC due date along with plan to ensure staffing is maintained in such a manner as to be able to meet all the needs of the residents in care.
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at least one occasion.
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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: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4