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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 02/23/2021
Date Signed: 02/23/2021 11:15:02 AM



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
12/17/2020 and conducted by Evaluator Amy Goldenberg
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20201217104942
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: 63DATE:
02/23/2021
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Gemma Deoso, AdministratorTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Resident's medication is not being properly administered
Resident's care needs are not being met due to insufficient staffing
Residents' call button is not being responded to timely
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Amy Goldenberg is conducting a visit to conclude this agency's investigation into the complaint allegations noted above. LPA met with Gemma Deoso, Administrator and discussed the findings of the investigation conducted and written by LPA Susan Parker below.

"The investigation consisted of the following: LPA Parker interviewed 9 residents, 1 staff, reviewed resident medication logs, reviewed the call button log, and LPA documented her attempt to reach facility staff via telephone with no response. The investigation revealed the following: Regarding the allegation "resident's medication is not being properly administered".....The Department was not given a specific name as to whose medication was not being properly administered, so LPA Susan Parker interviewed 9 residents.
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: 02/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2021
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 3
Control Number 18-AS-20201217104942
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: 02/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/25/2021
Section Cited
CCR
87411(a)
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Personnel Requirements-General (a)
Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.

This requirement is not met as evidenced by:
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Administrator will submit a written plan explaining how the facility will comply with the requirement to have sufficient staffing to meet residents' needs. This plan will be submitted to Licensing by 2/25/21.
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Based on resident/staff interviews there are not enough staff employed to meet residents' needs, and to respond to residents' call buttons in a timely manner. This poses a potential threat to the residents' health & safety.
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Type B
02/25/2021
Section Cited
CCR
87465(c)(2)
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Incidental Medical & Dental Care (c)(2)
Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
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Administrator will submit a written plan explaining how this requirement will be met, including that staff will be re-trained in this procedure. Written plan, and proof of retraining will be submitted to Licensing by 2/25/21.
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Based on resident interviews, residents do not always receive their medications at the time the dosage is to be given. This poses a potential threat to the health & safety of the residents.
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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: 02/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 18-AS-20201217104942
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: 02/23/2021
NARRATIVE
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Of those 9 residents, 3 residents said their medications were not being properly administered, meaning the medications are not always given at the correct time.

Regarding the allegation "Residents' care needs are not being met due to insufficient staffing"......LPA Parker interviewed 9 residents, and of those 9 residents, 6 residents felt their needs were not being met due to insufficient staffing. Various needs were not met because staff are not always available. LPA Parker called the facility 3 times on 1/20/21 and no staff answered the telephone.

Regarding the allegation "Resident's call button is not being responded to timely".....Of the 9 residents LPA Parker interviewed, 3 residents said it takes more than 15 minutes for a staff person to respond to them or they have not gotten a response at all.

Based on resident/staff interviews, review of the medication logs, and review of the call button log, the preponderance of evidence standard has been met and all 3 allegations are Substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8 is cited on the attached LIC 9099D."

LPA Goldenberg reviewed this report and appeal rights with the facility representative, Gemma Deoso and copies were provided during the exit interview.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3