331881547-5-3-2024-18-AS-YDEO-D4WP6W-20240503110302

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881547
Report Date: 05/03/2024
Date Signed: 05/03/2024 11:04:27 AM

Document Has Been Signed on 05/03/2024 11:04 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	ARLINGTON HEIGHTS ASSISTED LIVING AND MEMORY CARE		FACILITY NUMBER:	331881547
ADMINISTRATOR:	CHOUDRY, SAHER		FACILITY TYPE:	740
ADDRESS:	2844 PRISCILLA ST		TELEPHONE:	(951) 522-1425
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92506
CAPACITY:	6	CENSUS: 0	DATE:	05/03/2024
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Saher Choudry, Licensee		TIME COMPLETED:	11:15 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Yolanda Delgado conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. At approximately 9:00 AM, LPA met with Licensee/Administrator Saher Choudry. An initial application to operate a Residential Care for the Elderly facility (RCFE) was submitted to the Central Applications Bureau (CAB) on 1/11/2024 for a total capacity of six, five (5) non-ambulatory and one (1) bedridden residents. Fire clearance was granted on 02/16/2024. LPA Delgado observed the following: Structure: Facility was a one-story house with four (4) resident bedrooms, two (2) resident bathrooms, living room, dining area and kitchen. There is an attached two car garage in the front of the house. Heating/Cooling System: Central heating and air conditioning system installed with a central panel located in the dining area to control entire house. Bedrooms: Each resident bedroom #1 shared room, #2 shared room, #3 private room, #4 shared room for bedridden resident. Four (4) resident bedrooms were not adequately furnished with bed, chair, however closet, appropriate linens, adequate lighting, and an operable smoke alarm was sufficient. (Continued on page 2)

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda Delgado	TELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024

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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ARLINGTON HEIGHTS ASSISTED LIVING AND MEMORY CARE	FACILITY NUMBER: 331881547
	VISIT DATE: 05/03/2024

NARRATIVE

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Bathrooms:
The two (2) resident bathrooms has a working toilet, wash basin, and shower with an adequate supply of paper towels, toilet paper, and soap. At 10:05 AM, LPA tested the water temperatures in the resident bathrooms. LPA verified water temperature was measured at 108.9 degrees Fahrenheit.
Kitchen/Laundry:
An adequate supply of dishes, glasses, utensils, pots and pans were observed. Knives/sharp instruments were secured in a locked cabinet located in the kitchen. There was adequate room for food storage. LPA observed the stove to be operational. Refrigerator/freezer were in working condition and had sufficient storage for perishable food. There was adequate seating for meals for all clients. Laundry room with washer and dryer was located inside the garage. Laundry detergents and cleaning supplies were observed in garage away from residents.
Living/Family room:
There was a living/family room with seating for all clients and TV.
Linens and Hygiene Supplies:
An adequate supply of linens was stored in a cabinet in the main hallway of the residence.
Yards/Outside:
Patio tables and chairs were observed in the backyard. There was a gate on the East and West sides of the property have a self-latching door. All outdoor pathways were free of obstructions.
Emergency Phone Numbers, and Exit Plan:
Facility sketch, Obudsman poster and Let-Us-No posters observed posted, however no exit plans were posted.

(Continued on page 3)

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda Delgado	TELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024

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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ARLINGTON HEIGHTS ASSISTED LIVING AND MEMORY CARE	FACILITY NUMBER: 331881547
	VISIT DATE: 05/03/2024

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(Continued from page 2)

General items:
One (1) fire extinguishers were charged and located in the kitchen. Seven (7) dual smoke alarm/carbon monoxide detectors were tested and were observed to be working, Client records will be stored in a locked closet. First Aid kit with required components, and locked area for medication storage was observed. LPA observed a facility phone and it was verified to be operational as evidenced by LPA dialing the number to trigger a ring. Emergency water supply was observed however the required 72-hour emergency food supply was not discernible from the regular food supply. Component III was completed on 04/25/2024 at the RO in Riverside.

Pre-Licensing is incomplete and the following corrections to be resolved by 5/6/2024:

obtain a separate 72-hour emergency food supply
obtain additional emergency water
post exit plans at exit areas
obtain PPE supplies
re-arrange room #2 setup
obtain additional chair, lamp, bedside table and chest drawers for rooms #1, room #2
obtain emergency lightning for each resident
obtain paper towels stands
obtain night light for hallway
replace 3 exterior window screens

An exit interview was conducted, and a copy of this report was given.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda Delgado	TELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024

LIC809 (FAS) - (06/04)

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