331880741-2-8-2023-18-AS-DMUN-CNWQK9-20230210111359

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 02/08/2023
Date Signed: 02/08/2023 12:14:35 PM

Substantiated

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
08/25/2022 and conducted by Evaluator Stephanie Torres

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20220825122852

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:	02/08/2023
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Kurt Niebres, Administrator		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Licensee is not maintaining the facility in good repair

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to deliver the findings of the investigation into the above allegation. The LPA met with Kurt Niebres, Administrator, and informed him of the purpose of the visit.

It was alleged there is an insect infestation and the facility is in disrepair. The LPA started the investigation on August 31, 2022. Staff interview reported there are cockroaches in the breakroom. The LPA observed cockroaches in one resident bedroom on October 17, 2022. Photographs were obtained showing one spider, one fly, a cockroach and other unknown insects throughout the facility. The report also alleged electrical faceplates were missing in resident bedrooms. Administrator Niebres was interviewed and confirmed the faceplates were missing in bedroom 140. The LPA received photographs showing one missing cover. It was also reported the sink in bedroom (140) had some damage. The Administrator confirmed the sink was tilting away from the wall and photographs were obtained showing cracked dry wall repair coming off near the sink. The report also alleged the facility's over hand was damaged, near the parking lot entrance. Administrator

Substantiated

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: 02/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023

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

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 18-AS-20220825122852

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/08/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/08/2023 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	MAINTENANCE AND OPERATION: (a) The facility shall be clean, safe, sanitary & in good repair at all times. Maintenance shall include provision of maintenance services & procedures for the safety & well-being of residents, employees & visitors. This requirement was not met, as evidenced by:	1 2 3 4 5 6 7	Photos and invoices were submitted. POC cleared.
	8 9 10 11 12 13 14	Based on photographs, interviews, and observation, the Licensee did not ensure the facility was maintained in good repair. This posed a potential risk to the residents in care.	8 9 10 11 12 13 14
CCR	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	8 9 10 11 12 13 14		8 9 10 11 12 13 14

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 Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 18-AS-20220825122852

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: 02/08/2023

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
26
27
28
29
30
31
32

Niebres was interviewed and confirmed the area was damaged due to a delivery truck hitting the overhang around November 2021. Photographs were obtained showing the stucco had come off and was revealing the wire underlay. Finally, it was alleged the facility had a leak near the exterior entrance of the facility. Administrator Niebres was interviewed and confirmed the information. Therefore, based on observations and photographs, this allegation is deemed SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. A citation will be issued in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8).

An exit interview was conducted with Niebres; this report was reviewed and a copy provided, along with instructions on appeal rights.

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3