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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880741
Report Date: 06/07/2023
Date Signed: 06/07/2023 08:57:57 PM


Document Has Been Signed on 06/07/2023 08:57 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: 76DATE:
06/07/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
06:30 PM
MET WITH:Kurt Niebres, AdministratorTIME COMPLETED:
09:00 PM
NARRATIVE
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Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to continue the investigation of complaint #18-AS-20230524095653. The LPA met with Kurt Niebres, Administrator, and informed him of the purpose of the visit.

During the visit the LPA was approached by Resident One (R1) who asked the LPA to open the doors at the main entrance of the facility, so they could exit the building. The LPA approached the sliding doors of the main entrance of the building and observed the doors would not open. The LPA approached the medication room, found Staff One (S1) and requested their assistance with opening the doors. S1 made a comment about how it was already past 7:00 PM, and that R1 needed to call in order to get back into the building. The LPA observed S1 use a step to turn a swith an the top of the sliding door in order to allow the doors to open from the inside of the facility. This poses an immediate threat to the health and safety of the residents in care. A citation will be issued.

An exit interview was conducted; this report was reviewed with Niebres and a copy, along with instructions on appeal rights, was provided.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 782-4807
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2023
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 06/07/2023 08:57 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: 06/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/08/2023
Section Cited
CCR
87203

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FIRE SAFETY: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement was not met, as evidenced by: Based on observation, the Licensee did not ensure the facility was maintained in
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The Administrator stated staff would be informed on how to properly use the settings on the slidding doors to allow for individuals to leave the building while outside of business hours. He stated proof on notification would be provided to the LPA by POC due date.
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conformity with regulations for the protection of life and property. The LPA approached the sliding doors of the main entrance of the building and observed the doors would not open. This poses an immediate threat to the health and safety of the 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: Jazmond D HarrisTELEPHONE: (951) 782-4807
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2023
LIC809 (FAS) - (06/04)
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