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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881547
Report Date: 12/09/2024
Date Signed: 12/09/2024 12:04:00 PM

Document Has Been Signed on 12/09/2024 12:04 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ARLINGTON HEIGHTS ASSISTED LIVING AND MEMORY CAREFACILITY NUMBER:
331881547
ADMINISTRATOR/
DIRECTOR:		CHOUDRY, SAHERFACILITY TYPE:
740
ADDRESS:2844 PRISCILLA STTELEPHONE:
(951) 522-1425
CITY:RIVERSIDESTATE: CAZIP CODE:
92506
CAPACITY: 6CENSUS: 6DATE:
12/09/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:37 AM
MET WITH:Saher Choudry, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:12 PM
NARRATIVE
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Licensing Program Analyst (LPA) Yolanda Delgado conducted a case management visit for residents in care, during the visit, there were working utilities, food supply was sufficient, staff available to provide care & supervision; it was discovered one (1) of two (2) staff did not have criminal background clearance. No residents were observed to be without basic needs and services.

Facility will be cited for 87355(b) with civil penalties of $500 and plan of correction is due 12/10/2024.

An exit interview was conducted with Saher Choudry and a copy of this report, 809-D, LIC421BG and appeal rights were provided.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 12/09/2024 12:04 PM - It Cannot Be Edited


Created By: Yolanda Delgado On 12/09/2024 at 11:44 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ARLINGTON HEIGHTS ASSISTED LIVING AND MEMORY CARE
FACILITY NUMBER: 331881547

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/10/2024
Section Cited
CCR
87355(b)

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Criminal Record Clearance: (e) All individuals...shall prior to working, residing or volunteering in a licensed facility: (b) Prior to the Department issuing a license, the applicant, administrator and any adults other than a client, residing in the facility shall have a criminal record clearance or exemption.
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Licensee agrees to have S1 complete fingerprints by POC due date and obtain clearance/association in order continue to have S1 work at the facility. Licensee to provide LPA Delgado with proof of submitted request by 5pm on the due date indicated.
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This requirement was not met as evidenced by:

Based on observation and interviews, the Licensee did not comply with the above regulation with at one staff (S1). LPA Delgado learned that S1 does not have fingerprint clearance and are not associated to this facility. This is an immediate safety risk to all 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 Harris
LICENSING EVALUATOR NAME:Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2024


LIC809 (FAS) - (06/04)
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