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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880741
Report Date: 10/21/2022
Date Signed: 10/21/2022 04:48:15 PM


Document Has Been Signed on 10/21/2022 04:48 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: 75DATE:
10/21/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:10 PM
MET WITH:Kurt Niebres, AdministratorTIME COMPLETED:
04:55 PM
NARRATIVE
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Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to follow up on recently received information relating to complaints # 18-AS-20200728144334 and #18-AS-20200804151148. The LPA met with Wellness Nurse, Tammy Chavez, and informed her of the purpose of the visit.

During the investigation of complaint #18-AS-20200728144334 the allegation, "Staff stole resident's personal belongings," was investigated and deemed unsubstantiated on September 28, 2021. However, on December 23, 2021, LPA Torres received additional evidence relating to the alleged violation. The LPA was provided a video recording which shows staff entering Resident One’s (R1s) room and confiscating R1s video camera mounted on the wall, without R1s consent. The video also shows R1 repeatedly asking for the camera back and staff refusing to comply. Therefore based on the subsequent information received, a citation of personal rights is being issued.

During the investigation of complaint #18-AS-20200804151148 the allegation, "Facility staff caused injury to resident," was investigated and deemed unsubstantiated on February 15, 2022. The investigation could not determine whether R1 sustained any injuries from the altercation involving Staff One (S1). However, the recording did reveal R1, in an effort to retrieve their camera that was taken by staff, pushed S1. S1 then pushes past R1, causing the resident to stumble back slightly. The recording also shows S1 and R1 yelling at each other throughout the altercation. Therefore based on the subsequent information received, a citation of personal rights is being issued.

An exit interview was conducted with Chavez in which this report was reviewed and a copy provided, along with Appeal Rights.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2022
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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Document Has Been Signed on 10/21/2022 04:48 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/24/2022
Section Cited

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PERSONAL RIGHTS OF RESIDENTS IN ALL FACILITIES: (a) Residents in all RCFEs shall have all of the following personal rights: To be accorded safe, healthful & comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by: Based on video recording
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the licensee did not comply with the section cited above. Video recording shows R1 pushed S1. S1 then pushes past R1, causing the resident to stumble back slightly. This posed an immediate risk to the personal rights of the resident in care.
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Type B
11/04/2022
Section Cited

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PERSONAL RIGHTS OF RESIDENTS IN ALL FACILITIES: Residents in all RCFE's shall have all of the following personal rights: To wear their own clothes; to keep and use their own personal possessions, including their toilet articles; and to keep and be allowed to spend their own money. This requirement
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was not met as evidenced by: Based on video recording the Licensee did not ensure resident was able to keep their own personal possession. Video recording shows staff entering R1's room & confiscating R1s video camera. This posed an immediate threat to the personal rights of R1.
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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: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2022
LIC809 (FAS) - (06/04)
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