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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880741
Report Date: 05/25/2023
Date Signed: 05/25/2023 03:28:38 PM


Document Has Been Signed on 05/25/2023 03:28 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 AC/SC, 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:
05/25/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Administrator, Kurt NiebresTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs), Kathleen Banrasavong and Stephanie Martinez, conducted an unannounced visit to the facility to address violations observed during a review of records. The LPAs met with Administrator, Kurt Niebres, and informed him of the purpose of the visit.

On May 23rd, 2023, LPA Martinez received Plan of Corrections (POC) paperwork from Administrator, Kurt Niebres regarding in service training for proper documentation. The LPA observed signatures from staff no longer working for the facility. The LPA conducted interviews with said staff; It was reported those individuals were not working for the facility in May of 2023. The Administrator was interviewed and reported the incorrect proof of training was submitted to the LPA by accident.

Furthermore, additional training on the same subject matter was observed on file. The training was incomplete due to not being provided to all care staff members. The POC was not completed within the appropriate time frame, therefore, a civil penalty will be issued.

These violations pose a potential threat to the health, safety, and personal rights of the residents in care.

This report was reviewed with Kurt Niebres and a copy of the report was given.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Kathleen BanrasavongTELEPHONE: 951-248-0319
LICENSING EVALUATOR SIGNATURE:
DATE: 05/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/25/2023
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 05/25/2023 03:28 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 AC/SC, 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: 05/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/25/2023
Section Cited
CCR
87405(d)(5)

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ADMINISTRATOR - QUALIFICATIONS & DUTIES: (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7)...(5) Good character and a continuing reputation of personal integrity. This requirement was not met as evidence by: based on records and interviews.
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The Administrator stated a statement of certification would be submitted regarding review and understanding of Administrator Qualifications and Duties.
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The licensee didn't ensure the Admin. maintained a continuing reputation of personal integrity. LPA received a POC regarding training on proper documentation with signatures from staff no longer employed.
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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) 248-0318
LICENSING EVALUATOR NAME: Kathleen BanrasavongTELEPHONE: 951-248-0319
LICENSING EVALUATOR SIGNATURE:
DATE: 05/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/25/2023
LIC809 (FAS) - (06/04)
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