331880741-9-9-2022-18-AS-DMUN-CN72G4-20230117162231

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 09/09/2022
Date Signed: 09/09/2022 04:15:33 PM

Substantiated

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
09/09/2022 and conducted by Evaluator Stephanie Torres

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20220909110427

FACILITY NAME:	ARLINGTON RIVERSIDE SENIOR COMMUNITY		FACILITY NUMBER:	331880741
ADMINISTRATOR:	KURT NIEBRES		FACILITY TYPE:	740
ADDRESS:	4609 ARLINGTON AVE		TELEPHONE:	(951) 462-1025
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92504
CAPACITY:	150	CENSUS: 72	DATE:	09/09/2022
		UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	Kurt Niebres, Administrator		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Facility failed to repair air conditioning unit in resident bedroom

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to initiate the investigation into the above allegation. The LPA met with Kurt Niebres, Administrator, and informed him of the purpose of the visit.

The LPA conducted staff/resident interviews, reviewed records, and took copies of pertinent documentation. Regarding the allegation, "Facility failed to repair air conditioning unit in resident bedroom," it was alleged the air conditioning unit in Resident One's (R1's) bedroom does not work and they had to purchase their own fan for use. Interviews revealed the central air conditioning unit is not currently operable in the bedroom of Resident One (R1) and Resident Two (R2) and, as a result, the residents have experienced periods of uncomfortablly high temperatures. Interviews revealed the unit has not been operable for at least four (4) weeks. Administrator Niebres was interviewed and reported he had no knowledge of whether the AC unit in the bedroom was operable or not. Staff interviews revealed maintenance companies have been contacted;

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2022

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 3

Control Number 18-AS-20220909110427

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: 09/09/2022

NARRATIVE

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however, repairs have yet to be made. A records review revealed no proof of visits from or calls to maintenance companies servicing the unit. Therefore, this allegation is deemed SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. A citation will be issued in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8).

An exit interview was conducted; this report was reviewed with Niebres and a copy, along with LIC 811 and Appeal Rights, has been issued.

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 18-AS-20220909110427

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: 09/09/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/16/2022 Section Cited CCR 87303(b)	1 2 3 4 5 6 7	MAINTENANCE AND OPERATION: (b) A comfortable temperature for residents shall be maintained at all times. This requirement was not met, as evidenced by: Based on interviews, the Licensee did not ensure a comfortable temperature was maintained for residents.	1 2 3 4 5 6 7	The Administrator stated the ac unit will be repaired and a statement of certification will be submitted to the department by POC due date.
	8 9 10 11 12 13 14	Interviews revealed the central ac unit is not currently operable in the bedroom of R1 and R2 & the residents have experienced periods of uncomfortably high temperatures. This poses a potential threat to the health and safety of the residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2022

LIC9099 (FAS) - (06/04)

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