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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880741
Report Date: 01/23/2024
Date Signed: 01/23/2024 05:29:33 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
01/18/2022 and conducted by Evaluator Sara Martinez
COMPLAINT CONTROL NUMBER: 18-AS-20220118135256
FACILITY NAME:ARLINGTON RIVERSIDE SENIOR COMMUNITYFACILITY NUMBER:
331880741
ADMINISTRATOR:GEMMA DEOSOFACILITY TYPE:
740
ADDRESS:4609 ARLINGTON AVETELEPHONE:
(951) 462-1025
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY:150CENSUS: DATE:
01/23/2024
UNANNOUNCEDTIME BEGAN:
04:02 PM
MET WITH:Executive Director - Morgan Williams TIME COMPLETED:
05:35 PM
ALLEGATION(S):
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Facility's signal system is not operable
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced visit to conclude and deliver findings to an investigation regarding the allegation listed above. LPA was granted entry and met with Executive Director Morgan Williams who was informed of the purpose for the visit.

Regarding the allegation “Facility’s signal system is not operable”, it was reported that due to staffs’ walkie talkies not working they could not respond to residents calling for assistance. Interview with residents and staff revealed that due to staff pagers not being maintained in working condition, staff did not respond to residents’ call button request in a timely manner. Interview with residents revealed when a call button is pushed staff usually respond to the residents after an hour of the button being pushed. Interview with staff revealed the pagers provided by the facility for staff to use did not work due to the pagers having connectivity issues.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024
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 3
Control Number 18-AS-20220118135256
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
VISIT DATE: 01/23/2024
NARRATIVE
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Staff interviews revealed due to the pagers not working staff would take longer to respond to the residents or some residents would not be attended to due to the request being missed. A Situational Awareness and Response Assistant (SARA) log was obtained and reviewed for January 18, 2022. Multiple call requests were shown to have lasted for at least thirty minutes. Therefore, based on interviews and record review, the allegation “Facility's signal system is not operable” has been deemed SUBSTANTIATED at this time.

A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

An exit interview was conducted where a copy of this report was discussed with and provided along with copies of the LIC9099C, LIC9099D, and Appeal Rights.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20220118135256
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: 01/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/30/2024
Section Cited
CCR
87303(i)(1)
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87303 Maintenance and Operation
(i)Facilities shall have signal systems...(1)All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: This requirement was not met based on:
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Licensee will ensure facility signal system is operational and will provide proof of correction by the POC date.
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Based on interviews and record review, the licensee did not ensure to meet this requirement as evidenced by not having an operable signal system which is a potential health and safety risk to 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.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3