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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880741
Report Date: 02/27/2023
Date Signed: 02/27/2023 04:36:52 PM


Document Has Been Signed on 02/27/2023 04:36 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: 77DATE:
02/27/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Jenesa McDonald, Business Office Manager TIME COMPLETED:
04:40 PM
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Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to address a violation observed during the investigation of complaint #18-AS-20220315112632. The LPA met with Business Office Manager (BOM), Jenesa McDonald, and informed her of the purpose of the visit.

During the investigation it was revealed, through staff and resident interviews, Resident One (R1) sustained multiple falls around March 2022. No unusual incident reports were found to have been received by the Department. This poses a potential threat to the health, safety and personal rights of the residents in care. A citation will be issued.

In addition, the LPA received information on February 27, 2023 of homeless individuals entering the facility and taking up residence in bedrooms 219 and 220. The LPA toured the bedrooms with staff and observed discarded items strewn about the floor. Interviews and records revealed there is a suspicion of Resident Two (R2) bringing in homeless individuals into the facility. According to the BOM, two unknown individuals were observed to be entering into the facility driveway on February 24, 2023, however, no individuals were observed in the facility by staff when a search was conducted of the whole property. Further follow up will be conducted if additional information is received.

An exit interview was conducted; this report was reviewed with McDonald and a copy was provided, along with instructions on appeal rights.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 02/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2023
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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Document Has Been Signed on 02/27/2023 04:36 PM - It Cannot Be Edited

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: 02/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/13/2023
Section Cited

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REPORTING REQUIREMENTS: (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the
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Per the BOM, a statement will be submitted ensuring facility staff will report incidents within the required time period.
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occurrence of any of the events specified in (A) through (D) below...Any incident which threatens the welfare, safety or health of any resident, ... No unusual incident reports were found to have been received by the Department.
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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: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 02/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2023
LIC809 (FAS) - (06/04)
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