331880741-12-21-2022-18-AS-DMUN-CNNVPB-20230202153628

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 12/21/2022
Date Signed: 12/21/2022 03:34:53 PM

Unsubstantiated

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
08/11/2022 and conducted by Evaluator Stephanie Torres

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20220811090816

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: 75	DATE:	12/21/2022
		UNANNOUNCED	TIME BEGAN:	03:07 PM
MET WITH:	Kurt Niebres, Administrator		TIME COMPLETED:	03:40 PM

ALLEGATION(S):

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Resident developed maggot infested wound while in care.

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 her visit.

During the investigation, the LPA conducted staff interviews, reviewed records, and took copies of pertinent documentation.

Pertaining to the allegation, "Resident developed maggot infested wound while in care," it was alleged Resident One (R1) was observed to have maggots inside their wound on or around August 10, 2022. Interviews revealed R1 is receiving specialized care from a Hospice agency. A review of the facility records revealed no hospice records were available and/or on file. Records were requested from R1's designated hospice agency. Outside Care Provider Communication Forms were obtained and revealed R1 received Hospice care on July 26, 2022; July 27, 2022; July 30, 2022 (3); August 03, 2022; August 05, 2022; August 07, 2022; and August 10, 2022.

Unsubstantiated

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: 12/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20220811090816

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: 12/21/2022

NARRATIVE

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Per the Communication Forms R1 received wound care on August 03, 2022; August 05, 2022; and August 10, 2022. No records were received indicating maggots were observed in the resident's wound. An interview conducted with a hospice staff member reported no observations of maggots in R1's wound. Staff interviews revealed R1 was observed to have maggots in their wound on or around August 10, 2022. In addition, a photograph was obtained showing a wound sustained near the coccyx and maggots underneath the wound. No reports were received to provide information as to how the maggots developed. Therefore, due to a lack of information, this allegation is deemed UNSUBSTANTIATED at this time. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove the alleged violation occurred.

This report was reviewed with Niebres and a copy was provided.

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2022

LIC9099 (FAS) - (06/04)

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