<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880741
Report Date: 03/21/2022
Date Signed: 01/26/2023 10:53:10 AM


Document Has Been Signed on 01/26/2023 10:53 AM - 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: 64DATE:
03/21/2022
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Kevin Longa Ha, LicenseeTIME COMPLETED:
10:47 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
A virtual Office Meeting, facilitated by Regional Manager, Reyna Lacey, Licensing Program Manager, Deborah Mullen, and Licensing Program Analyst, Stephanie Torres, was held with Licensee, Kevin Long Ha. The purpose for the meeting was to address the facility's current Fire Clearance status.

On March 08, 2022, the Department was made aware the facility's Fire Clearance did not address limitations specific to non-ambulatory residents remaining on the first floor only. The Department was also made aware that the City of Riverside's Conditional Use Permit limiting the facility to a capacity of 110.

The discrepancies were discussed with the Licensee and he indicated they are in the process of relocating non-ambulatory residents to the first floor and that this would be completed by March 23, 2022. Licensee also reported he will be submitting an application to the City of Riverside, Planning Department, and will notify the Community Care Licensing Division (CCLD) once submitted. Licensee was advised that increased visits will be conducted until a determination from the city has been received. Licensee was provided with contact information for the Planning Department.

This report was reviewed with Licensee and a copy was provided via email.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2022
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 1