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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880741
Report Date: 01/20/2023
Date Signed: 01/20/2023 05:30:48 PM


Document Has Been Signed on 01/20/2023 05:30 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:
01/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Administrator, Kurt NiebrasTIME COMPLETED:
05:45 PM
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Licensing Program Analyst (LPA) Janira Arreola, made an unannounced visit on 1/20/2023 at 2:40 pm. in order to conduct an annual visit with a focus on infection control. LPA met with Administrator, Kurt Niebres who was informed of the purpose of the visit.

LPA proceed to conduct a walk through of the facility. LPA observed there was a central entry point where screenings are conducted for facility visits. LPA observed the resident bedrooms that would be used as isolation rooms. . The facility has a cleaning plan in place to disinfect and clean the high touch surfaces of the facility and the isolation rooms. The staff have leave in case of contact or testing positive for COVID-19. The staff have been trained on how to properly don and doff the PPE equipment, and there is a plan of care in place to attend to those residents that would be in the isolation rooms.

Technical advisory notes were issued for the following:
  • Staff have not been N95 fit tested
  • Staff did not wear face masks during the time of the visit
  • (2) COVID signs were observed at the facility, the facility needs to place these throughout
  • The administrator stated they are not sure if all new hires have been fully vaccinated
  • The administrator stated that they do not have a 30 day supply of PPE
  • The resident restrooms were observed to be lacking in paper towels and hand soap
  • Staff are not conducting temperature checks at the beginning of their shift, and are taking resident temperature daily
  • The facility has not submitted a infection control plan for COVID or Monkey pox

No deficiencies were cited at the time of the visit.

An exit interview was conducted where this report was reviewed and provided to administrator, Kurt Niebres
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/20/2023
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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