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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 02/24/2023
Date Signed: 02/24/2023 06:12:23 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
07/06/2021 and conducted by Evaluator Amy Goldenberg
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210706135655
FACILITY NAME:ARLINGTON RIVERSIDE SENIOR COMMUNITYFACILITY NUMBER:
331880741
ADMINISTRATOR:GEMMA DEOSOFACILITY TYPE:
740
ADDRESS:4609 ARLINGTON AVETELEPHONE:
(951) 462-1025
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY:150CENSUS: 78DATE:
02/24/2023
UNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Kurt Niebres, AdministratorTIME COMPLETED:
06:30 PM
ALLEGATION(S):
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Resident did not receive medication according to physician orders
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Amy Goldenberg is conducting this unannounced visit to conclude this agency's investigation into the allegations noted above. During the course of this investigation interviews were conducted with staff and residents. LPA obtained pertinent records for (R1). LPA toured the facility bedrooms to asses bed sheet condition and the kitchen. LPA reviewed the facility menus, the food supply and observed dinner meal service on 02/24/2023. LPA conducted Eight (8) resident interviews. Investigation revealed the following: R1 no longer resides at the facility. It is alleged that R1 did not receive their eye drops following their eye surgery surrounding July 2021 time period. Investigation of the medication records revealed no record of eye drops for R1. The medication Technician found the ordered eyedrops in R1’s bedroom. Interview revealed that the facility staff did not know if R1 was administered eye drops because they admitted they had not given the drops to R1.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023
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 6
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 Amy Goldenberg
COMPLAINT CONTROL NUMBER: 18-AS-20210706135655

FACILITY NAME:ARLINGTON RIVERSIDE SENIOR COMMUNITYFACILITY NUMBER:
331880741
ADMINISTRATOR:GEMMA DEOSOFACILITY TYPE:
740
ADDRESS:4609 ARLINGTON AVETELEPHONE:
(951) 462-1025
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY:150CENSUS: 78DATE:
02/24/2023
UNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Kurt Niebres, AdministratorTIME COMPLETED:
06:30 PM
ALLEGATION(S):
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Facility is in disrepair
Residents are not being fed nutritious meals
Resident's sheets are not changed as required
INVESTIGATION FINDINGS:
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 Licensing Program Analyst (LPA) Amy Goldenberg is conducting this unannounced visit to conclude this agency's investigation into the allegations noted above. During the course of this investigation interviews were conducted with staff and residents. LPA obtained pertinent records for (R1). LPA toured the kitchen. LPA reviewed the facility menus, the food supply and observed dinner meal service on 02/24/2023. LPA conducted Eight (8) resident interviews. Investigation revealed the following: R1 no longer resides at the facility.

It is alleged that the facility kitchen is not working properly, and the facility was serving fast food. Interviews revealed that during July 2021 the facility kitchen did have a leak but did not impair the ability to use the kitchen. Interview revealed that the facility Administrator was serving meals due to unexpected resignation of the cooks.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 18-AS-20210706135655
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: 02/24/2023
NARRATIVE
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 She indicated she utilized the kitchen. It is unclear if the leak in the kitchen or sudden staffing loss were the cause of the issues with meal service. LPA tour of the kitchen did not reveal any disrepair. The dinner meal observed consisted of ravioli with tomato sauce, broccoli, and garlic bread on the side. LPA observed milk, juice and coffee available for residents and condiments on the table. Review of the food stores reveal ingredients for making nutritious meals. Review of the menu indicates nutritious meals are being served. Eight (8) out of eight (8) residents interviewed indicate the food is good or has gotten better and indicated that their room is cleaned once per week which includes making their bed and changing their sheets. It was alleged that bed sheets are not being changed.

We have found the complaint allegation is unsubstantiated, although the allegation may have happened or is valid: there is not a preponderance of the evidence to prove that the alleged violation occurred. A copy of this report is being reviewed with and furnished to the facility representative.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 18-AS-20210706135655
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: 02/24/2023
NARRATIVE
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 R1’s physician report dated 08/8/2021 indicates that R1 is unable to administer their own medications.

We have substantiated the complaint allegation as valid and that a violation has occurred based on the preponderance of available evidence. A copy of this report along with appeal rights are being reviewed with, and furnished to the facility representative. Please see LIC 9099D.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 18-AS-20210706135655
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: 02/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/24/2023
Section Cited
CCR
87465(a)(4)
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Incidental Medical and Dental Care: The licensee shall assist residents with self-administered medications as needed. The facility did not meet this requirement as evidenced by lack of knowledge of R1's eye drop order following surgery.
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Administrator to submit LIC9098 self certifying understanding of the regulation cited and submit to LPA by 02/25/2023.

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This poses a risk to the healthand safety of residents in care.
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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: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6