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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880741
Report Date: 01/26/2023
Date Signed: 01/26/2023 11:46:22 AM


Document Has Been Signed on 01/26/2023 11:46 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: 76DATE:
01/26/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:07 AM
MET WITH:Kurt Niebres, AdministratorTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to follow up on violations observed by the Department. The LPA met with Administrator, Kurt Niebres, and informed him of the purpose of her visit.

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 facility put a plan in place on March 21, 2022, to relocate all non-ambulatory residents from the second floor to the first. On April 15, 2022, Administrator Niebres informed the LPA all non-ambulatory residents had been moved from the second floor to the first.

During the investigation of complaint #18-AS-20230111090802, the LPA found, in Resident One's (R1's) Physician's Report for Residential Care Facilities for the Elderly (RCFE), documentation of a non-ambulatory status. Interviews and a Resident Roster revealed R1 is residing on the second floor, in room 203. This poses an immediate threat to the health and safety of the residents in care. A citation and civil penalty will be issued (this is a repeat violation; the facility was cited for the same violation on April 19, 2022).

In addition, on January 20, 2023, LPA, Janira Arreola, during an Annual Inspection, observed multiple staff members not to be listed on the facility employee roster. On January 17, 2023, LPA Torres notified Administrator Niebres of the need to ensure all staff working in the facility needing to be listed on the personnel roster. A Personnel Report (LIC 500) revealed twelve (12) staff members not to be listed on the employee roster. This poses a potential threat to the health, safety, and personal rights of the residents in care.

An exit interview was conducted; this report was reviewed with Niebres and a copy was provided, along with LIC 811, LIC 421IM, LIC 421BG (2), and Appeal Rights.

SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2023
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 01/26/2023 11:46 AM - 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: 01/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/27/2023
Section Cited

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FIRE SAFETY: All facilities shall be maintained in conformity with the regs. adopted by the State Fire Marshal for the protection of life & property against fire & panic. This requirement was not met, as evidenced by: Based on observation, the Licensee did not ensure the facility was
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Administrator stated R1 would be moved to the first floor and a statement will be provided ensuring no additional non-amb residents are on the 2nd floor.
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maintained in conformity with the regs. adopted by the State Fire Marshal. Interviews and records revealed R1 is residing on the 2nd floor in bedroom 203. R1 has a non-ambulatory status documented in their physician's report. This poses an immediate threat to the health & safety of the resident in care.
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Type B
01/30/2023
Section Cited

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CRIMINAL RECORD CLEARANCE: (e) All individuals subject to a criminal record review pursuant to H&S Code...1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)... This requirement
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Administrator agreed to provided LIC 9182s and identification cards for all 12 staff.
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was not met, as evidenced by: Based on records, the Licensee did not ensure a transfer of a criminal record clearance was requested for staff working in the facility. A LIC 500 revealed 12 staff members not to be listed on the employee roster.
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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: 01/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2