331880741-5-10-2023-18-AS-JDHS-CS7VWA-20230526164736

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 05/10/2023
Date Signed: 05/10/2023 12:18:07 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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
03/02/2022 and conducted by Evaluator Stephanie Torres

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20220302103827

FACILITY NAME:	ARLINGTON RIVERSIDE SENIOR COMMUNITY		FACILITY NUMBER:	331880741
ADMINISTRATOR:	KURT NIEBRES		FACILITY TYPE:	740
ADDRESS:	4609 ARLINGTON AVE		TELEPHONE:	(951) 462-1025
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92504
CAPACITY:	150	CENSUS: 77	DATE:	05/10/2023
		UNANNOUNCED	TIME BEGAN:	08:37 AM
MET WITH:	Kurt Niebres, Administrator		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff failed to provide resident with appropriate supervision

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to deliver the findings of the investigation into the above allegation. The LPA met with Kurt Niebres, Administrator, and informed him of the purpose of the visit.
An allegation was received by the Department alleging facility staff failed to appropriately supervise Resident One (R1) leading to multiple falls. The investigation included interviews with staff, residents, and third parties; records review and records collection. R1 was interviewed and reported they had no knowledge of falling frequently while at the facility. R1 did report being found on the floor by staff and sustaining bruises to their arms and legs. Staff interviews revealed R1 would be found on the floor multiple times a week. Third party interviews revealed facility staff did contact the office of R1's primary care physician on 03/01/2022, 02/20/2022, 02/02/2022, and 01/29/2022 to report frequent falls. Staff interviews revealed staff would check on R1 more frequently due to observed falls. However, no documentation of falls or of staff observations of R1 were found on file at the facility. Therefore, due to insufficient information, this allegation is deemed UNSUBSTANTIATED at this time. This report was reviewed with Niebres and a copy was provided.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 782-4807
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

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