331880741-7-13-2021-18-AS-NBRN-CP3QKG-20230215111418

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 07/13/2021
Date Signed: 07/13/2021 03:07:11 PM

Unfounded

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
07/06/2021 and conducted by Evaluator Stephanie Torres

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20210706133142

FACILITY NAME:	ARLINGTON RIVERSIDE SENIOR COMMUNITY		FACILITY NUMBER:	331880741
ADMINISTRATOR:	GEMMA DEOSO		FACILITY TYPE:	740
ADDRESS:	4609 ARLINGTON AVE		TELEPHONE:	(951) 462-1025
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92504
CAPACITY:	150	CENSUS: 56	DATE:	07/13/2021
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Lori Matsushita, Administrator		TIME COMPLETED:	03:10 PM

ALLEGATION(S):

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Facility not posting contact information for ombudsman.
Facility is without a first aid kit.

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 Administrator, Lori Matsushita, and informed her of the purpose of the visit.

On this date the LPA conducted staff interviews, reviewed records and took copies of pertinent documentation. Pertaining to the allegation, "Facility not posting contact information for ombudsman," it was alleged there was no adequate phone number posted for the local Long Term Care Ombudsman (LTCO) office at the facility. The LPA toured the facility with the Administrator and observed posted the contact information for the Riverside County LTCO office. The LPA called the contact number listed on the poster and was connected with the appropriate office. The contact information was also observed to be posted in an accessible area where residents gather daily. Therefore, based on observation, this allegation is deemed UNFOUNDED.

Regarding the allegation, "Facility is without a first aid kit," it was alleged the facility's first aid kit was missing

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2021

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-20210706133142

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: 07/13/2021

NARRATIVE

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bandages, neosporin, basic dressing adhesives in their medication room. The LPA observed two (2) first aid kits in the facility medication room. The LPA audited the contents of the kits and found the following items: bandages and sterile first aid dressings. Per regulation 87465(a)(9)(a) through (f), Neosporin is not a required item to be included in the first aid kit, though it was available. Furthermore, the facility has two (2) additional first aid kits located near the lobby area. Therefore, based on observation, this allegation is deemed UNFOUNDED.

A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

This report was reviewed with Administrator Matsushita and a copy was provided.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2021

LIC9099 (FAS) - (06/04)

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