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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 12/14/2022
Date Signed: 12/14/2022 01:11:17 PM

Unfounded


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
03/03/2022 and conducted by Evaluator Stephanie Torres
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220303130355
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
UNANNOUNCEDTIME BEGAN:
08:18 AM
MET WITH:Kurt Niebres, AdministratorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Facility did not follow their program plan
Facility overcharged a resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to continue the investigation into the above allegations. The LPA met with Administrator, Kurt Niebres, and informed him of the purpose of her visit.

The investigation was started on March 10, 2022; staff interviews were conducted, records were reviewed and copies of pertinent information obtained.

Pertaining to the allegation, "Facility did not follow their program plan," it was alleged Resident One (R1) was admitted to the facility with a prohibited health condition. R1's Physician's Report for Residential Care Facilities for the Elderly (RCFE), conducted on January 31, 2022, indicates R1 did have a health condition requiring specialized care, though it was not a prohibited health condition. Therefore, based on a records review, this allegation is deemed UNFOUNDED.
Unfounded
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 18-AS-20220303130355
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: 12/14/2022
NARRATIVE
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Regarding the allegation, "Facility overcharged a resident," it was alleged the facility overcharged R1, who has a capacity deficit, for an admission fee and alert necklace. Interviews and a records review were conducted; it was found R1 was charged a fee for admission and for an alert necklace, however, no regulatory requirements exist indicating what a facility is permitted to charges. Therefore, this allegation is deemed UNFOUNDED.

A finding that the complaint is unfounded means the allegation is false, could not have happened, and/or is without a reasonable basis.

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
LIC9099 (FAS) - (06/04)
Page: 2 of 2