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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880741
Report Date: 05/10/2023
Date Signed: 05/10/2023 12:31:29 PM


Document Has Been Signed on 05/10/2023 12:31 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
RIVERSIDE ASC, 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:
05/10/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:37 AM
MET WITH:Kurt Niebres, AdministratorTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to follow up on violations observed during the investigation of complaint # 18-AS-20220302103827. The LPA met with Kurt Niebres, Administrator, and informed him of the purpose of her visit.

During the complaint investigation the LPA found, through staff interviews, Resident One (R1) had sustained multiple falls during the period of February and March 2022. R1 sustained a fall on or around March 01, 2022 and was transferred to the hospital. No incident report was submitted to the Department regarding the resident's hospitalization. It was also found there was no documentation on file regarding any change of condition and/or falls sustained by the resident. In addition, an incomplete Admission Agreement was observed on file for R1. The agreement did not contain information on what services would be provided to R1 while at the facility. These violations posed a potential threat to the health, safety, and/or personal rights of the resident. A citation will be issued.

An exit interview was conducted; this report was reviewed with Niebres, and a copy was provided, along with instructions on appeal rights.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 782-4807
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2023
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 05/10/2023 12:31 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
RIVERSIDE ASC, 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: 05/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/17/2023
Section Cited

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OBSERVATION OF THE RESIDENT: The licensee shall ensure that residents are regularly observed for changes in physical & mental...functioning & that appropriate assistance is provided... When changes such as...deterioration of mental ability or a physical health condition are observed, the licensee
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The Administrator stated in-service training will be conducted with all care staff regarding documentation procedures.
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shall ensure that such changes are documented... This requirement wasn't met, as evidenced by: Based on records review, the Licensee didn't ensure changes to R1's health were documentation. No documentation was observed on file regarding any change of condition &/or falls sustained by R1.
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Type B
05/12/2023
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 & to the person responsible for the resident within 7 days of the occurrence of any of the
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The Administrator stated an incident report will be submitted for R1's hospitalization.
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events specified... below...(D) Any incident which threatens the welfare, safety or health of any resident...This requirement was not met, as evidenced by: Based on interviews and records, the Licensee did not ensure the licensing agency was notified in writing of R1's hospitalization on 03/02/2022.
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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: Jazmond D HarrisTELEPHONE: (951) 782-4807
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 05/10/2023 12:31 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
RIVERSIDE ASC, 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: 05/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/17/2023
Section Cited

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ADMISSION AGREEMENT: The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any. This requirement was not met as evidenced by: Based on records review, the Licensee did not ensure an
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The Administrator stated a statement will be submitted ensuring Admission Agreements will be completed for newly admitted residents.
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Admission agreement was completed with R1. The agreement did not contain information on what services would be provided to R1 while at the facility.
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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: Jazmond D HarrisTELEPHONE: (951) 782-4807
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2023
LIC809 (FAS) - (06/04)
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