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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881480
Report Date: 08/20/2025
Date Signed: 08/20/2025 12:46:54 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
06/27/2024 and conducted by Evaluator Janette Romero
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20240627092850
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: 97DATE:
08/20/2025
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Wellness Coordinator, Breanna JonesTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Illegal eviction
Food service is not provided in a timely manner to residents in care
Staff do not ensure residents dietary plan is followed
INVESTIGATION FINDINGS:
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On 8/20/2025, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced visit to the facility to deliver findings regarding the allegations listed above. LPA met with Wellness Coordinator, Breanna Jones who was informed of the purpose of the visit.

Regarding the allegation, “Illegal eviction” it was alleged Resident 1 (R1) was pressured by the facility to sign onto the Assisted Living Waiver (ALW) Program, was informed all the services would be covered, and now received an unlawful eviction notice. LPA reviewed R1’s 30-day eviction notice dated 06/12/2024 issued for nonpayment of the basic services within (10) days of the due date. R1’s eviction notice contained all the required elements. LPA also reviewed R1’s "Payer Detail Ledger" provided by the facility dated 07/08/2024 noting their balance owed. R1 was interviewed and confirmed receiving an eviction notice but refused to provide any other information regarding this allegation. Based on a facility staff interview, LPA received the following information. Staff deny pressuring R1 to participate in the ALW program.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Carolyn Tuba
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
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 6
Control Number 18-AS-20240627092850
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: 08/20/2025
NARRATIVE
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R1’s admission agreement dated 05/31/2022 was reviewed and revealed R1 was a private pay resident being charged $2500 a month. Staff reported R1 was previously participating in a program that did not continue after the change of ownership. Staff reported that residents participating in this program were given the option to work with the program to identify new facilities contracted with that program so R1 could continue to receive the benefits of that program. Staff report R1 chose to remain in the facility and enroll in the ALW program. LPA reviewed the ALW Patient’s Rights, Freedom of Choice Form, and Amenity Form dated in October of 2023 reflecting R1’s signatures and acknowledging awareness to the ALW participant’s role and responsibility. Due to R1 declining to provide any additional information, LPA was unable to confirm R1’s signature to validate the ALW program consent forms, or to validate if they were pressured to participate in the ALW program. Staff reported R1 was required to pay their portion of the agreed upon rate and the ALW program would pay another portion. Staff reported R1 was not paying their portion of the agreed upon rate. LPA was unable to confirm with R1 if payments were being made or not. LPA received a copy from the facility of an unlawful detainer issued for R1. Therefore, this allegation is unsubstantiated.

Regarding the allegation, “Food service is not provided in a timely manner to residents in care” it was alleged food is served late or not at all. LPA made contact with the reporting party who was unable to identify the affected residents nor provide additional details. As a result, LPA conducted an interview with a sample of the population. Facility staff was interviewed and refuted the allegation. Staff reported breakfast is served from 7:30 a.m. to 9:00 a.m., lunch from 11:45 a.m. to 1:00 p.m., and dinner from 4:45 p.m. to 6:00 p.m. Eight (8) residents were interviewed, and eight (8) of eight (8) reported meals are served in a timely manner. Therefore, this allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was reviewed and provided to Wellness Coordinator Jones.

SUPERVISORS NAME: Carolyn Tuba
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 18-AS-20240627092850
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: 08/20/2025
NARRATIVE
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Regarding the allegation, “Staff do not ensure residents dietary plan is followed” it was alleged Resident 2 (R2) requires a diabetic diet, and the facility does not accommodate them. R2 was interviewed and corroborated the allegation. However, LPA reviewed R2’s physician’s report and the “Other Conditions” section states, “DM II” but the "Special Diet" subsection is marked "No". A staff interview conducted reported certain residents prescribed diabetes medications may not require a special diet, as some medications require a regular diet to prevent dangerously low blood sugar levels. The staff showed LPA R2’s physician’s orders and reported it listed a prescription medication commonly used to help manage type 2 diabetes. LPA made several unsuccessful attempts to contact the physician listed in R2’s physician’s report to confirm whether R2 required a special diet. Staff reported R2 would tell them, they could not consume sugary foods however, R2 is known to request high-sugar desserts such as chocolate cake with meals. The facility reported they never received an updated physician’s report or medical record to indicate R2 ever required a special diet while they resided in the facility. A staff interview conducted reported R2 has since moved out of the facility and there is no forwarding contact information for them. Therefore, this allegation is unsubstantiated.
SUPERVISORS NAME: Carolyn Tuba
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
06/27/2024 and conducted by Evaluator Janette Romero
COMPLAINT CONTROL NUMBER: 18-AS-20240627092850

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: 97DATE:
08/20/2025
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Wellness Coordinator, Breanna JonesTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Licensee is not properly addressing issue with pests in the facility
INVESTIGATION FINDINGS:
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On 8/20/2025, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced visit to the facility to deliver findings regarding the allegations listed above. LPA met with Wellness Coordinator, Breanna Jones who was informed of the purpose of the visit.

Regarding the allegation, “Licensee is not properly addressing issue with pests in the facility” it was alleged the facility has failed to address the pest problem involving bed bugs and roaches. LPA made contact with the reporting party who was unable to identify the affected residents nor provide additional details. Administrator, Molly Bowie was interviewed and reported the facility has an ongoing contract with Orkin to provide pest control services twice per month and additionally as needed. LPA reviewed Orkin’s contract with the facility dated 07/18/2023 documenting an agreement to service the facility for pests twice a month and additionally as requested.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Carolyn Tuba
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 18-AS-20240627092850
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/03/2025
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by:
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Administrator reported the facility will conduct an all staff training on 8/28/2025 regarding proper practices to report, document, and follow up on pest signs/sightings. POC will be emailed to LPA by close of business on 9/3/2025 to allow for any contingencies.
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Based on interviews conducted and records reviewed, the facility was unable to demonstrate they took appropriate action to mitigate the pest sightings reported in specific resident rooms. This poses a potential health 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: Carolyn Tuba
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 18-AS-20240627092850
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: 08/20/2025
NARRATIVE
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One (1) of four (4) residents interviewed corroborated the allegation. Three (3) of four (4) residents interviewed reported although they have experienced issues with bed bugs or roaches in their rooms, a professional pest control company treated their rooms promptly. However, LPA reviewed the facility’s pest observations log which noted on 3/8/2024 and 3/27/2024, three (3) resident rooms were identified to have sightings of bedbugs/roaches and the log's “Corrective Actions Taken” column was left blank. LPA conducted a witness interview with Orkin who reported there is no documentation that the three (3) resident rooms identified in the pest observations log and the additional resident room identified during the resident interviews received treatment on or around the reported dates. Administrator Bowie reported during the identified incident time-frames, the facility did not work with any other pest control company besides Orkin. Facility staff was unable to provide documentation to demonstrate the facility took appropriate action to mitigate the pest sightings reported in the specific resident rooms. Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore this allegation is found to be substantiated. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099 D. An exit interview was conducted, and a copy of this report, LIC 9099-D, and Appeal Rights were reviewed and provided to Wellness Coordinator Jones. Administrator Molly Bowie called Wellness Coordinator Jones and implemented the plan of correction with LPA.
SUPERVISORS NAME: Carolyn Tuba
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6