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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881480
Report Date: 03/14/2024
Date Signed: 03/14/2024 10:51:58 AM

Document Has Been Signed on 03/14/2024 10:51 AM - 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:RIVERSIDE RETIREMENT VILLA LLCFACILITY NUMBER:
331881480
ADMINISTRATOR:WILLIAMS, MORGANFACILITY TYPE:
740
ADDRESS:4609 ARLINGTON AVETELEPHONE:
(921) 462-1025
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY: 236CENSUS: 73DATE:
03/14/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Morgan Williams - AdministratorTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility for the purpose of conducting a Pre-Licensing visit for Change of Ownership. Analyst met with Applicant Adam Zenou and Administrator Morgan Williams, who LPA Colvin informed of the purpose of today's visit, and toured the facility with the Administrator.

ACTIVITIES: Inside and outside, there are areas for residents to use for their leisure. Activity room has activities for residents such as puzzles, books, and television. There is additionally planned activities schedule posted at the entrance and a staff member stationed at the room to aid residents.

FOOD SERVICE: The kitchen area was observed for the ability to serve food and cleanliness. Dishes, utensils and glasses are present and in good condition. Facility has both perishable and non-perishable supply of food to satisfy the 2 day and 7 day requirements. Refrigerator was observed to be at 40 degrees and the walk-in freezer was 0 degrees.



EMERGENCY PREPAREDNESS: Facility has an emergency exit plan in place a posted in plain view at the facility and in each hallway. Facility was found to have operational smoke detectors and carbon monoxide detectors, and fire extinguishers. Applicant has completed and submitted a Mitigation Plan for Infection Control for the facility as well. Facility is equipped with generator to provide electricity in case of an emergency. LPA Colvin observed emergency disaster supplies (including food and water) in a designated locked storage room.

ADMINISTRATION/MEDICATION: A locked medication room with additionally locked medication carts are present and where all medication is stored. Records are additionally maintained in the locked medication room along with first aid supplies.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2024
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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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: RIVERSIDE RETIREMENT VILLA LLC
FACILITY NUMBER: 331881480
VISIT DATE: 03/14/2024
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PHYSICAL PLANT: Fire Clearance was granted for 222 non-ambulatory residents and 10 bedridden residents on 2/22/24 by the Riverside City Fire Department. The facility is set-up with resident bedrooms and bathrooms, kitchen, dining room, activity rooms, offices, laundry rooms, and lounges/common areas.
Exits to the outside were observed to be unlocked for clients' and staff's use in case of emergency, and there are no locked gates around the facility restricting emergency exit. LPA Colvin tested the facility's hot water in multiple rooms and observed it to be measuring at 86, 108.5, 103.6, 106.5, 90.3, 107.7, and 109 degrees. Administrator had maintenance increase the temperature on the water heater during today's inspection, and LPA Colvin retested the rooms with the lowest water temperature. LPA Colvin observed some rooms to be reaching 105 degrees, but others remained below 105. LPA Colvin observed required accommodations in residents' bedroom and bathrooms, including beds, linen, storage furniture, and lamps. Trash bins located in resident bedrooms were observed to not have tight-fitting lids, and LPA Colvin observed that some of these residents require assistance with incontinence, as evidenced by presence of diapers and wipes. Smoke detectors and carbon monoxide units are all operable, as observed by LPA Colvin when LPA Colvin tested them. Common areas such as dining and living rooms were observed to be clean and in good condition.

REQUIRED POSTINGS: LPA Colvin observed the facility to have informational postings for residents in two main areas of the facility. LPA Colvin observed postings included Residents Rights, Resident Counsel, Theft and Loss Policy, information for Long-Term Care Ombudsman, "See Something, Say Something" Complaint Poster for Community Care Licensing. LPA Colvin did not observe a posted Admissions Agreement, which Administrator Morgan Williams stated was available upon request.

AREAS REQUIRING CORRECTION: LPA Colvin noted the following items which need to be fixed prior to the completion of the change of ownership of this facility and issuing of a new license:
· Trash bins in resident bedrooms were not observed to have tight-fitting lids
· Water temperature was reading below 105 degrees in multiple resident bedrooms

Analyst will inform Centralized Applications Bureau (CAB) about the Pre-Licensing visit and Applicant being ready to proceed with the licensing process once corrections have been made. Applicant may self certify to LPA Colvin when corrections have been made. An exit interview was conducted with Applicant Adam Zenou and Administrator Morgan Williams, and a copy of the report was provided.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024
LIC809 (FAS) - (06/04)
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