331880741-10-11-2022-18-AS-NBRN-CKJQBA-20221025120113

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 10/06/2022
Date Signed: 10/11/2022 12:14:14 PM

Unsubstantiated

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
02/17/2021 and conducted by Evaluator Amy Goldenberg

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20210217104754

FACILITY NAME:	ARLINGTON RIVERSIDE SENIOR COMMUNITY		FACILITY NUMBER:	331880741
ADMINISTRATOR:	GEMMA DEOSO		FACILITY TYPE:	740
ADDRESS:	4609 ARLINGTON AVE		TELEPHONE:	(951) 462-1025
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92504
CAPACITY:	150	CENSUS: 70	DATE:	10/06/2022
		UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	Kurt Niebres, Administrator		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Facility has insufficient staffing to meet the residents’ needs
Staff failed to administer resident's medication in a timely manner
Staff fail to provide adequate food service
Staff fail to order resident's refills in a timely manner

INVESTIGATION FINDINGS:

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This unannounced visit by Amy Goldenberg, Licensing Program Analyst (LPA), is being conducted to conclude this agency’s investigation into the complaint allegations mentioned above.

During the course of this investigation LPA interviewed six (6) residents, interviewed two (2) staff, reviewed two (2) residents records and obtained a copy of the list of special diets ordered. LPA requested copies of the resident roster, staffing schedules for the weeks of 2/21/21 through 3/6/21, facility menu, dining schedule, plan for meal substitutes, copies of two weeks of food delivery invoices, and LPA toured the kitchen and assessed the food supply during three visits. LPA additionally requested medication treatment records and physician's reports for five (5) residents. LPA received a copy of Dietician's food and nutrition report dated 09/30/2022.

Unsubstantiated

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: 10/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022

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-20210217104754

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: 10/06/2022

NARRATIVE

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It is alleged that there are insufficient staff to meet the needs of R1. R1 moved from the facility during the COVID-19 pandemic in 2021 and has been unable to be interviewed. Three (3) of Six (6) residents interviewed state that assistance is sometimes delayed. Review of the staffing schedules do not reveal an obvious staffing shortage. It is alleged that R1 did not receive his insulin timely and that the medications were not reordered. LPA review of R1's records for medication did not reveal any evidence that medications were not given as ordered or were not reordered by the facility. It is alleged that staff fail to provide adequate food service. LPA review of the food supply, review of menus and three (3) of six (6) residents interviewed are satisfied or relayed no complaints regarding food service.
Based on the available information, LPA has determined that there is not enough evidence to establish or disprove if a violation has occurred as detailed in the allegations in regard to R1.

We have found the complaint allegations unsubstantiated, although the allegation may have happened or are valid: there is not a preponderance of the evidence to prove that the alleged violation occurred. A copy of this report is being reviewed with and furnished to the facility representative.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy Goldenberg	TELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022

LIC9099 (FAS) - (06/04)

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