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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880741
Report Date: 04/25/2023
Date Signed: 04/25/2023 02:11:36 PM


Document Has Been Signed on 04/25/2023 02:11 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: 75DATE:
04/25/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Kurt Niebres, AdministratorTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs), Stephanie Torres and Sara Martinez, conducted a follow up visit to the facility to address violations observed during the investigation of complaints #18-AS-20220523155617 and #18-AS-20230320161847. The LPAs met with Kurt Niebres, Administrator, and informed him of the purpose of the visit.

During the investigation of complaint #18-AS-20220523155617 LPA Torres observed a Medication Administration Record (MAR) for Resident One (R1), for the month of May 2022. The report, which was initialed by staff, indicated the resident was receiving two types of medication injections. A medication list for R1 revealed the resident was only prescribed to receive one medication injection, once daily. Records indicated R1 was not receiving their medications as prescribed. This posed an immediate health and safety risk to the resident in care. A citation and civil penalty (due to the facility violating this regulation in the past) will be issued. In addition, the MAR for R1 for May 2022 showed initials of Staff One (S1). S1 was interviewed and confirmed they have provided injections to R1. S1 is not an appropriately skilled professional. According to R1's Physician's Report for Residential Facilities for the Elderly (RCFE), the resident is unable to manage the administration of this medication on their own. During the investigation of complaint #18-AS-20230320161847 LPA Torres observed no admission agreement on file for R2 on March 23, 2023. Interviews revealed R2 was admitted to the facility approximately the first week of March 2023. The Administrator was interviewed and reported no admission agreement had yet been signed. Secondly, no written record of care was observed on file for R2. The Administrator was interviewed and reported no written record of care was created. In addition, interviews revealed facility staff were providing assistance to R2 in emptying their catheter bag. A record review revealed no documentation of training on how to change catheter bags was on file prior to the LPA's visit. A citation will be issued.

An exit interview was conducted with Niebres; this report was reviewed 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: 04/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2023
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 04/25/2023 02:11 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: 04/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/26/2023
Section Cited

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INCIDENTAL MEDICAL AND DENTAL CARE: (c) If the...physician has stated... the resident is unable to determine their own need for nonprescription PRN medication but can communicate their symptoms...staff...shall be permitted to assist the resident w/ self-administration, provided all of the
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The Administrator stated R1's family member is now administering the medication to the resident. He reported that a statement would be provided.
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following...is met: (2)...the medication is given according to...directions. This requirement was not met as evidenced by: Based on records the Licensee didn't ensure R1 received medication as prescribed. A MAR indicated R1 received 2 types of injections. A med. list revealed R1 was only prescribed 1 type of med. injection.
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Type A
04/26/2023
Section Cited

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INJECTIONS: (a) The licensee shall be permitted to accept or retain a resident who requires... subcutaneous...injections if the injections are administered by...an appropriately skilled professional.
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The Administrator stated a statement would be submitted indicating a review was done regarding resident injection administration.
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This requirement was not met, as evidenced by: Based on records the Licensee did not ensure R1 received injections from an appropriately skilled professional. A MAR for R1 for May 2022 showed initials of S1. S1 is not an appropriately skilled professional.
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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: 04/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 04/25/2023 02:11 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: 04/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/02/2023
Section Cited

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INDWELLING URINARY CATHETER: (b) In addition to Section 87611, the licensee shall be responsible for the following: (2) Ensuring that the bag & tubing are changed by an appropriately skilled professional should the resident require assistance. (B) There shall be written documentation by an appropriately
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The Administrator stated proof of documentation will be submitted to the Department.
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skilled professional outlining the instruction of the procedures delegated & the names of the facility staff who have been instructed. This requirement was not met, as evidenced by: Based on records, the Licensee did not ensure training provided to staff was documented.
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Type B
05/02/2023
Section Cited

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ADMISSION AGREEMENT: (c) Admission agreements shall be signed & dated, acknowledging the contents of the document, by the resident or the resident’s representative, if any, & the licensee or the licensee’s designated rep. no later than 7 days following admission. This requirement was not met
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The Administrator stated proof of the admission agreement being completed would be submitted.
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as evidenced by: Based on records & interview the Licensee did not ensure an admission agreement was completed for R1 within 7 days. LPA observed no agreement on file for R2. Interviews revealed R2 was admitted to the facility approximately the 1st week of March 2023.
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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: 04/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 04/25/2023 02:11 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: 04/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/09/2023
Section Cited

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RESIDENT PARTICIPATION IN DECISIONMAKING: (a) Prior to, or within 2 weeks of the resident’s admission, the licensee shall arrange a meeting...to prepare a written record of the care the resident will receive in the facility...This requirement was not met, as evidenced by:
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The Administrator stated proof of the written record of care will be submitted once completed.
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Based on records review and interviews, the Licensee did not ensure a written record of care was created for R2. No written record of care was observed on file for R2.
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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: 04/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2023
LIC809 (FAS) - (06/04)
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