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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 06/12/2023
Date Signed: 06/12/2023 02:22:43 PM

Substantiated


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
06/08/2023 and conducted by Evaluator Stephanie Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20230608155629
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:
06/12/2023
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Kurt Niebres, AdministratorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff is refusing to accept resident back into care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to start the investigation into the above allegation. The LPA met with Kurt Niebres, Administrator, and informed him of the purpose for the visit. A report was received alleging Staff One (S1) refused to allow Resident One (R1) to return to the facility following a temporary admission to a skilled nursing facility. The investigation included staff/resident interviews, records review, and records collection. S1 was interviewed and denied the allegation. S1 stated they notified the skilled nursing facility that R1 could only return to the facility under the supervision of a hospice agency for their Restricted Health Condition (RHC). A third party reported S1 did indicate they could not accept R1 back at the facility until the resident was on services with a hospice agency. In addition, Progress Notes from May 30, 2023, revealed S1 had already been notified of the healing of R1's RHC and of the resident being ready for discharge. Therefore, based on interviews and records, this allegation is deemed SUBSTANTIATED. A finding that the complaint is substantiated means the allegation is valid because the preponderance of the evidence standard has been met. An exit interview was conducted with Niebres; this report was reviewed, and a copy was provided, along with instructions on appeal rights.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 782-4807
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 18-AS-20230608155629
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/19/2023
Section Cited
CCR
87468.2(a)(20)
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Additional Personal Rights of Residents in Privately Operated Facilities: (a)..residents in private RCFEs shall have...the following... rights: (20) To be protected from involuntary transfers, discharges, & evictions. A licensee shall not involuntarily transfer/evict residents for reasons other than those permitted...
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The Administrator will provide S1 an inservice on the personal rights of residents and submit proof to the Department by POC due date. The Administrator stated R1 will be accepted back into the community.
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& shall comply w/ eviction & relocation protections...This requirement wasn't met as evidenced by: Based on interviews & records, the Licensee didn't ensure R1 was free from an involuntary transfer. S1 admitted to not allowing R1 to return to the facility unless under hospice. This posed a threat to the personal
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(continued) rights of R1.
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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: 06/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2