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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880741
Report Date: 01/10/2023
Date Signed: 01/10/2023 12:05:56 PM


Document Has Been Signed on 01/10/2023 12:05 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: 76DATE:
01/10/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Kurt Niebres, AdministratorTIME COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to continue the investigation of complaint #18-AS-20230104110943.

During the visit the LPA received information alleging facility staff failed to administer medication to Resident One (R1) from January 07, 2023 through January 09, 2023. The LPA reviewed records and conducted staff interviews. Interviews revealed R1 did not receive one medication on January 07, 2023 and January 08, 2023 because the medication package was empty. The LPA attempted to conduct an audit of the medication; however, interviews revealed the medication package was no longer available because the cycle ended on January 08, 2023. Two Narcotic and Antibiotic Drug Records were reviewed; no signatures indicating R1 received their medication the night of January 06, 2023 until the morning of January 09, 2023. According to Administrator Niebres, staff are trained to utilize the records for documentation purposes. Therefore, based on interviews and records review, R1 did not receive one of their medications. This posed an immediate health and safety threat to the resident in care. A citation and civil penalty (for a repeat violation will be issued).

An exit interview was conducted with Niebres; this report was reviewed, and a copy was provided along with LIC 421IM, LIC 811 and Appeal Rights.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 01/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2023
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 01/10/2023 12:05 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: 01/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/17/2023
Section Cited

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INCIDENTAL MEDICAL AND DENTAL CARE: (c) If the resident's physician has stated... the resident is unable to determine their own need for nonprescription PRN med. but can communicate their symptoms..., facility staff... shall be permitted to assist the resident with self-administration, provided all of the following
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Facility will conduct in-service with staff regarding reporting missing medications to management.
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requirements are met: (2) Once ordered by the physician the med. is given according to...directions. This requirement was not met, as evidenced by: Based on interviews & records, the Licensee did not ensure R1 received their medication on 01/07 and 01/08.
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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: 01/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2023
LIC809 (FAS) - (06/04)
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