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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880741
Report Date: 01/17/2023
Date Signed: 01/17/2023 04:50:56 PM


Document Has Been Signed on 01/17/2023 04:50 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: 74DATE:
01/17/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Kurt Niebres, AdministratorTIME COMPLETED:
05:00 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-20220825122852. The LPA met with Administrator, Kurt Niebres, and informed him of the purpose of her visit.

As of March 08, 2022 the facility does not have an approved fire clearance to allow non-ambulatory residents on the second floor. The facility put a plan in place on March 21, 2022 in order to relocate all non-ambulatory residents from the second floor to the first.

During this visit the LPA observed Resident One (R1) to be residing on the second floor of the building. R1 was observed to have a mechanical aide nearby and it was reported the resident does utilize the assistive device. Records review revealed R1 does meet the ambulatory requirements to reside on the second floor; however, does not appear to meet the definition of an ambulatory individual.

Administrator Niebres agreed to clarify R1's ambulatory status with the resident's physician and provide written verification by January 20, 2023.

An exit interview was conducted; 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: 01/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2023
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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