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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881480
Report Date: 07/21/2025
Date Signed: 07/21/2025 03:59:36 PM

Unsubstantiated


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
05/09/2024 and conducted by Evaluator Debbie Palacios
COMPLAINT CONTROL NUMBER: 18-AS-20240509101436
FACILITY NAME:ARLINGTON RIVERSIDE SENIOR COMMUNITYFACILITY NUMBER:
331881480
ADMINISTRATOR:WILLIAMS, MORGANFACILITY TYPE:
740
ADDRESS:4609 ARLINGTON AVETELEPHONE:
(951) 462-1025
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY:232CENSUS: 101DATE:
07/21/2025
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Molly Bowie, Excecutive DirectorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Resident developed a pressure injury due to neglect by staff.
Facility staff did not seek timely medical attention for residents pressure
injuries.
Facility staff leave residents in soiled bedding.
Facility staff do not respond to residents' call buttons in timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Debbie Palacios, conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegations. LPA met with Executive Director, Molly Bowie, to explain the purpose of the visit and the elements of the allegations.
The investigation consisted of observations, interviews with staff members and residents, and a review of records.
It was alleged that Residents R1 and R2 developed pressure injuries due to staff neglect and did not receive prompt medical care. Record review revealed Hospice Care documentation showed that R1 was receiving wound care three times a week. On May 8, 2024, R1 was examined by a physician who assessed the wound and scheduled a follow-up within two weeks. Following a two-week evaluation by a physician, R1 was admitted to Silverado Comfort Care Hospice on May 14, 2024, with medical orders to treat and cleanse wound.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Debbie Palacios
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2025
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-20240509101436
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: 331881480
VISIT DATE: 07/21/2025
NARRATIVE
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Hospice records and daily logs from May and June 2024 show that R2 also received wound care two to three times per week, with hospice nurses occasionally making two visits in a single day.

Regarding the allegation that staff left residents in soiled bedding, interviews conducted with residents revealed they have not experienced neglect in this regard. Residents reported that when they need prompt assistance, they use their call buttons and get assisted.

It was also alleged that facility staff do not respond to resident’s call buttons in a timely manner to respond promptly to call buttons, two out of six residents reported experiencing delays when requesting assistance. Four out of six residents reported that staff respond to the call buttons in a timely manner, approximately within 15 minutes. Staff interviews revealed that telephones had been installed in resident bedrooms to improve emergency communication. During daytime hours, calls are routed to the receptionist; during the night, calls are transferred to the Med-Tech room.

Although the allegations may have happened or is valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

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

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Debbie Palacios
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2