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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880741
Report Date: 03/02/2021
Date Signed: 03/02/2021 03:03:55 PM

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:GEMMA DEOSOFACILITY TYPE:
740
ADDRESS:4609 ARLINGTON AVETELEPHONE:
(951) 462-1025
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY:150CENSUS: 63DATE:
03/02/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Gemma Deoso, AdministratorTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Amy Goldenberg is conducting this case management visit to address areas of concern observed during a complaint investigation visit which are not part of the investigation. On 02/25/2021 LPA arrived to the facility at 0800. LPA noted that the front door was locked. LPA rang the bell and staff arrived shortly to assist LPA into the building. LPA later at approximately 1115 attempted to exit the front entry door. LPA found the door locked and required staff assistance to unlock the door in order to exit. LPA observed residents requesting the door to be unlocked by staff. LPA has determined that a violation has occurred through their observations, interviews and review of the approved fire clearance. Having a locked front door is a risk to the health and safety of residents in the event of an emergency and not approved per the facility fire clearance.

*A civil penalty assessment accompanies this deficiency.

LIC 809, LIC809D, LIC421IM and appeal rights were reviewed with and a copy was provided to Administrator Gemma Deoso.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2021
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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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: 03/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/02/2021
Section Cited

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All facilities shall maintain a fire clearance approved by the city, county...The facility has failed to meet this requirement as evidenced by: The facility does not have an approved fire clearance for
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locked doors. LPA observation that residents and herself required a staff to unlock the sliding front doors several times on 02/25/2021.
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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: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2021
LIC809 (FAS) - (06/04)
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