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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880741
Report Date: 12/14/2022
Date Signed: 12/14/2022 01:06:27 PM


Document Has Been Signed on 12/14/2022 01:06 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:
12/14/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:18 AM
MET WITH:Kurt Niebres, AdministratorTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to address a violation discovered during the investigation of ongoing complaints.

During the investigation of complaint #18-AS-20220303130355, it was discovered through interviews and records review that Resident One (R1) had a restricted health condition which was not be cared for by an appropriately skilled professional. R1's Physician's Report for Residential Care Facilities (RCFEs) indicates R1 had a health condition requiring specialized care, for which the resident was not able to manage on their own. This posed an immediate risk to the health of R1. A citation will be issued.

It was also discovered, through records and interviews, R1 was assessed a fee for an alert necklace/pendant. A review of the Admission Agreement on file for R1 did not indicate the charge. This posed a potential threat to the personal rights of R1. A citation will be issued.

This report was reviewed with Niebres and a copy was provided.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2022
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 12/14/2022 01:06 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: 12/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/14/2022
Section Cited

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INDWELLING URINARY CATHETER: (a) The licensee shall be permitted to accept or retain a resident who requires the use of an indwelling catheter under the following circumstances: (1) If the resident is physically and mentally capable of caring for all aspects of the condition except insertion and irrigation.
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The resident is no longer residing in the facility.
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This requirement was not met, as evidenced by: Based on records and interview, the Licensee did not ensure R1's restricted health condition was cared for by an appropriately skilled professional.
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Type B
12/21/2022
Section Cited

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ADMISSION AGREEMENTS: (g) Admission agreements shall specify the following: (3) Payment provisions, including the following: (C) Any fee that is charged prior to or after admission, shall be clearly specified. This requirement was not met, as evidenced by: Based on records review, the Licensee did
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The Administrator stated a copy of a new Admission Agreement with the appropriate language will be provided by POC due date.
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not ensure the fee for the alert necklace/pendant was clearly specified in the Admission Agreement on file for 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: 12/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2022
LIC809 (FAS) - (06/04)
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