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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880741
Report Date: 03/06/2023
Date Signed: 03/06/2023 03:56:01 PM


Document Has Been Signed on 03/06/2023 03:56 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: 74DATE:
03/06/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Jenesa McDonald, Business Office ManagerTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to address a violation observed during the investigation of complaint #18-AS-20230228144451. The LPA met with Business Office Manager (BOM), Jenesa McDonald, and informed her of the purpose of her visit.

During the investigation, the LPA conducted staff interviews and reviewed records. No death report could be found on file for Resident One (R1). Staff interview could not reveal whether a report had been submitted to the Department. A review of the Department's Regional Office log indicates no incident report was received from the facility for the death of R1. This poses a potential threat to the health, safety, and personal rights of the residents in care. Therefore, a citation will be issued.

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: 03/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 03/06/2023 03:56 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: 03/06/2023
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... the following: (1) A written report shall be submitted to the licensing agency... within 7 days of the occurrence of any of the events specified in (A) - (D) below...(A) Death
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The BOM stated a plan on the facility's reporting procedures will be sent to the Department by POC due date.
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of any resident...regardless of where the death occurred, including but not limited to... a hospital, en route to or from a hospital...This requirement wasn't met, as evidenced by: Based on records review, the Licensee didn't ensure a written report was submitted regarding R1's death.
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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: 03/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2