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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 12:30:58 PM


Document Has Been Signed on 01/17/2023 12:30 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:
12:15 PM
MET WITH:Kurt Niebres, AdministratorTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to address violations observed during the investigation of complaints #18-AS-20230104110943 and #18-AS-20230111090802. The LPA me with Kurt Niebres, Administrator, and informed him of the purpose of her visit.

During the investigation of complaint #18-AS-20230104110943, a report was received indicating no pre-appraisal was done prior to the admission of Resident One (R1). Administrator Niebres was asked about the allegation and he confirmed it was true. A review of R1's file was done and no appraisal was observed on file. Therefore, based on an interview and record review, it was found the facility violated pre-admission regulatory requirements. This posed a potential threat to the health, safety and personal rights of the resident in care. A citation will be issued.

During the investigation of complaint #18-AS-20230111090802, the LPA observed no cross report from the facility was made to the local ombudsman, the corresponding licensing agency, or the local law enforcement agency within twenty-four (24) hours. Administrator Niebres was interviewed and reported the incident had not yet been reported to any agencies as of today (01/17/2023). Therefore, based on interviews, it was found the facility violated regulatory reporting requirements. This posed a potential threat to the health, safety and personal rights of the residents in care. A citation will be issued.

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)
Page: 1 of 2


Document Has Been Signed on 01/17/2023 12:30 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: 01/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/24/2023
Section Cited

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PRE-ADMISSION APPRAISAL - GENERAL: (c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and
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The Administrator stated a statement will be submitted indicating pre-admission appraisals will be conducted prior to admission of any resident.
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Retention Limitations. This requirement was not met, as evidenced by: Based on interview and records review, the Licensee did not ensure an assessment was conducted on R1 prior to admission.
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Type B
01/24/2023
Section Cited

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REPORTING REQUIREMENTS: Any suspected physical abuse that does not result in serious bodily injury of an elder/dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within 24 hours...This requirement was not
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The Administrator stated a review of reporting requirements will be conducted and proof submitted to the Department.
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met as evidenced by: Based on interviews the Licensee did not ensure the suspected abuse was reported to the appropriate agencies. Administrator Niebres was interviewed & reported the incident had not yet been reported to any agencies as of 01/17/2023.
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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: 01/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2