331880741-2-27-2023-18-AS-DMUN-CPJ83C-20230301210920

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 02/27/2023
Date Signed: 02/27/2023 04:33:19 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
03/15/2022 and conducted by Evaluator Stephanie Torres

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20220315112632

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: 77	DATE:	02/27/2023
		UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	Jenesa McDonald, Business Office Manager		TIME COMPLETED:	08:40 PM

ALLEGATION(S):

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Resident was hit in the head resulting in multiple falls.

INVESTIGATION FINDINGS:

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Licensing Program Analyst, Stephanie Torres, conducted an unannounced visit to the facility to deliver the findings of the investigation into the above allegation. The LPA met with Business Office Manager, Jenesa McDonald, and informed her of the purpose of the visit.
A report was received alleging Resident One (R1) was hit in the head by an unknown individual, resulting in the resident sustaining multiple falls. R1 was interviewed and stated they do not know if someone hit them; however, the resident did report they had multiple falls while at the facility. Hospital medical records were obtained; records revealed R1 was hospitalized from March 01, 2022 until March 08, 2022. An assessment revealed there were no observations found of injuries to R1's head. Staff interviews revealed R1 was observed to have been found on the floor frequently, though the cause was unknown. 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 McDonald and a copy was provided.

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: 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.

LIC9099 (FAS) - (06/04)

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