331880741-9-9-2022-18-AS-DMUN-CLDQUE-20221121112834

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 09/09/2022
Date Signed: 09/09/2022 04:11:09 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
08/26/2022 and conducted by Evaluator Stephanie Torres

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20220826134748

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:	09/09/2022
		UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	Kurt Niebres, Administrator		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Staff were unavailable to grant entry to emergency personnel

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 the visit.

The LPA conducted staff/resident interviews, reviewed records, and took copies of pertinent documentation. Pertaining to the allegation, "Staff were unavailable to grant entry to emergency personnel," it was alleged that on August 23, 2022 emergency medical personnel arrived at the facility to find the doors locked and no staff available, preventing them from gaining immediate access to a resident calling for assistance. Staff and resident interviews revealed the facility's sliding doors, at the lobby, are locked in the evening. Interview reported emergency personnel did arrive at the facility to attend to Resident One (R1) some time in August 2022. It was reported emergency personnel would have encountered the lobby doors to be locked and needed staff assistance to gain access to the facility due to only one (1) staff member being available at the time. Therefore, based on interviews, this allegation is deemed SUBSTANTIATED. A finding that the complaint is

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: 09/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2022

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-20220826134748

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: 09/09/2022

NARRATIVE

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substantiated means the allegation is valid because the preponderance of the evidence standard has been met. A citation will be issued in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8). Additionally, due to a repeat citation, a civil penalty will be issued.

An exit interview was conducted; this report was reviewed with Niebres and a copy, along with LIC 9099D, LIC 811, LIC 421IM, and Appeal Rights.

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

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2022

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20220826134748

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: 09/09/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/10/2022 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 wasn't met, as evidenced by: Based on interviews, the Licensee didn't ensure staffing was sufficient. Interview	1 2 3 4 5 6 7	The Administrator stated additional staffing will be provided and certification will be sent to the Department by POC due date.
	8 9 10 11 12 13 14	reported emergency personnel did arrive at the facility to attend to R1 some time in August 2022. It was reported emergency personnel would have encountered the doors to be locked & needed staff assistance to gain access due to only 1 staff being available. This posed an immediate threat to the health & safety of R1.	8 9 10 11 12 13 14
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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 Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2022

LIC9099 (FAS) - (06/04)

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