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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197606145
Report Date: 12/15/2023
Date Signed: 12/15/2023 10:00:31 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/02/2021 and conducted by Evaluator Valeria Maldonado
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210302095454
FACILITY NAME:ARCADIA GARDENS RETIREMENT HOTELFACILITY NUMBER:
197606145
ADMINISTRATOR:PAT REDNERFACILITY TYPE:
740
ADDRESS:720 W. CAMINO REALTELEPHONE:
(626) 574-8571
CITY:ARCADIASTATE: CAZIP CODE:
91007
CAPACITY:200CENSUS: 162DATE:
12/15/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Pamela Parsons- Executive DirectorTIME COMPLETED:
10:15 AM
ALLEGATION(S):
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Resident sustained multiple severe pressure injuries while in care.
Staff did not seek medical attention for resident in a timely manner.
Staff did not notify resident's authorized representative of change in resident's condition
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) V. Maldonado conducted a subsequent complaint visit to continue the complaint investigation and deliver findings. LPA Maldonado met with (Staff Name & Job Title) and explained the purpose for the visit.

On 03/03/21, Licensing Program Analyst (LPA) Tao conducted the initial complaint investigation for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, the complaint investigation was conducted via tele-conferencing with Administrator, Pamela Parsons. During that virtual visit, LPA Tao conducted a health and safety check and requested a copy of the Staff and Resident roster. LPA Tao virtually toured the facility via Facetime with Administrator and observed that the facility was clean and in good repair. LPA observed nonperishable foods for a minimum of one week and perishable foods for a minimum of two days. LPA Tao observed wash basins, showers/bathtubs and toilets were operable and did not observe any immediate health and safety concerns.
(Report Continued on LIC9099-C...)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023
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 28-AS-20210302095454
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ARCADIA GARDENS RETIREMENT HOTEL
FACILITY NUMBER: 197606145
VISIT DATE: 12/15/2023
NARRATIVE
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On 03/05/21, a subsequent tele-visit was conducted by Investigator Jose Santana, during the visit, Investigator Santana interviewed staff from staff#1 (S1) to staff #21 (S21) which included Administrator Pamela Parsons; interviewed resident’s representative (RR); interviewed social worker (SW); obtained records from staff#9 (S9) and staff#20 (S20) to staff#23 (S23); and obtained records from police department (PD), hospital’s social worker (SW) and fire department (FD). IB reviewed resident#1 (R1)’s facility file and related documentation. Department was unable to interview resident#1 (R1) because R1 was passed away on 03/15/21.

Regarding allegation: Resident sustained multiple severe pressure injuries while in care.
It was alleged that a resident had multiple pressure injuries from resident’s leg, back and buttock area while in care. During the investigation, the department interviewed staff (S1) through (S21), reviewed R1’s facility file and reviewed documentation from outside providers. Per staff interviews, R1’s home health representative indicated they were not aware of R1 pressure injuries, were not notified by the facility of R1’s pressure injuries and did not receive any orders to treat R1’s pressure injuries. Home health staff were notified by the facility of R1s pressure injuries on 02/25/21. Interviews with staff revealed that not all staff were not made aware of R1’s pressure injuries and administrator failed to communicate R1’s pressure injuries to facility staff and with R1’s home health agencies. Per file reviews, on 02/10/21, R1 had redness on buttocks. On 02/18/21, S4 and S6 were aware of R1’s pressure injuries on resident’s back/buttock area. The facility did not address or document R1’s pressure injuries on R1’s care plan and did not notify R1’s family or responsible party of R1’s declining health and pressure injuries. On 02/25/21, S4 reported the resident had skin breakdown on resident’s hip and then notified R1’s home health care. On 02/26/21, the home health nurse came to assess R1 for pressure injuries and reported R1’s had unstageable pressure injuries on the resident’s back/buttock area and left heel. Although the facility contacted home health on 02/19/21, a home health assessment of R1’s pressure injuries was not obtained until 02/25/21. Thus, R1 developed multiple severe pressure injuries, an unstageable pressure injury to the back, buttock area and left heel, due to staff failing to address R1 pressure injuries in R1’s care plan and did not obtain home health for R1s pressure injuries upon first knowledge of R1s pressure injuries on 02/18/21.

Regarding allegation: staff did not seek medical attention for resident in a timely manner.
It was alleged that facility staff failed to provide timely medical care to resident who had several pressure injuries, including unstageable pressure injuries. The department interviewed staff (S1) through (S21), reviewed R1’s facility file and reviewed documentation from third party providers.
(Report Continued on LIC9099-C...)
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 28-AS-20210302095454
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ARCADIA GARDENS RETIREMENT HOTEL
FACILITY NUMBER: 197606145
VISIT DATE: 12/15/2023
NARRATIVE
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Staff, S4 and S6, observed R1 had pressure injuries on 02/18/21. Per administrator, staff had been performing medical treatment to resident’s wound care on the pressure injuries since the wounds were first observed on 02/18/21. Per R1s records review, there were no documents or written orders to reflect the facility obtained medical treatment for R1. Administrator reported R1 was under a full medical care from R1s home health nurses for wound care to breast and back. However, interviews with R1’s home health staff reported they provided care for R1’s existing medical condition to resident’s leg and breast, and did not provide home health services for R1’s pressure injuries to back and buttock area. Home health did not have written orders to treat R1’s pressure injuries on R1’s back and buttock area. On 02/25/21, facility staff notified R1s home health care to evaluate resident’s back and buttock area for R1’s skin breakdown. On 02/26/21, home health reported the resident had unstageable pressure injuries on the R1’s buttock area. Therefore, as a result of staff failing to obtain timely medical attention for R1 pressure injuries, R1 physically declined and developed several pressure injuries, resulting in R1 being sent to the hospital on 02/26/21 and admitted to hospice care on 02/27/21.

Regarding allegation: Staff did not notify resident's authorized representative of change in resident's condition.
It was alleged that staff did not inform resident’s family/authorized representative about the resident’s pressure injuries, ongoing physical decline, and the tremendous weight loss. Per staff interviews, staff were aware of R1 had pressure injuries on 02/18/21 which were reported to staff internally and on 02/25/21, R1 had skin breakdown which staff reported to home health. On 02/26/21, R1’s authorized representative was notified by R1’s home health representative that R1 had unstageable pressure injuries and the ongoing physical decline. Per staff interview, S6 admitted to knowledge of R1 having a change of condition on 02/18/21, however, staff did not inform R1’s representative about R1’s change in condition. During LPA Tao’s 12/08/23 telephone interview with administrator, the administrator admitted that facility only reported R1s change in condition internally within the facility and did not notify R1s family or representative. Thus, staff failed to inform resident’s authorized representative regarding R1s change of condition.

Based on interviews conducted and documents reviewed, the preponderance of evidence standard has been met, therefore, the above allegation is found to be Substantiated.
California Code of Regulations, (Title 22, Division 6 and Chapter 8), are being cited on the attached LIC9099-D.
(Report continued on LIC9099-C...)
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 28-AS-20210302095454
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ARCADIA GARDENS RETIREMENT HOTEL
FACILITY NUMBER: 197606145
VISIT DATE: 12/15/2023
NARRATIVE
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An immediate $500 civil penalty is being issued during today's visit due to the lack of care and supervision resulting in resident sustaining multiple pressure injuries.

The licensee was informed that a civil penalty might be assessed based on the Health & Safety Code 1569.49(e) or (f), or 1548(e) or (f), or 1568.0822(e) or (f).

An exit interview was conducted and a copy of the licensing report, along with appeal rights were provided to (Staff Name & Job Title).
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 28-AS-20210302095454
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ARCADIA GARDENS RETIREMENT HOTEL
FACILITY NUMBER: 197606145
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
12/16/2023
Section Cited
CCR
87631(a)(3)(B)
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87631 Healing Wounds
(a)(3)(B) All aspects of care performed by the medical professional and facility staff shall be documented in the resident's file.
This requirement was not met as evidenced by: Based on record review & staff interviews, the licensee did not (1) comply
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Licensee/ Administrator agrees to conduct staff training on regulation 87631 and resident care plan. Licensee agrees to submit a written statement of how this deficiency will be corrected by 12/15/23.
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comply with the section cited above; (2) document or update resident#1's Plan of Care; (3) provide care by medical professional to resident#1 who had unstageable pressure injuries, which poses an immediate health, safety or personal rights risk to persons in care.
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Additionally, Licensee will submit proof of staff training which includes staff signatures and dates by 1/3/23.
Request Denied
Type A
12/16/2023
Section Cited
CCR
87465(a)(1)
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87465 Incidental Medical and Dental Care
(a)(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.
This requirement was not met by evidence of
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Licensee/ Administrator agrees to conduct staff training on regulation 87465, provide proper medical care which includes pressure injuries for residents as required. Licensee agrees to submit a written statement of how this deficiency will be corrected by 12/15/23.
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Based on interviews and record reviews, Administrator failed to seek timely medical attention for resident#1 when resident sustained pressure injuries, which poses an immediate health, safety or personal rights risk to persons in care.
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Additionally, Licensee will submit proof of staff training which includes staff signatures and dates by 1/3/23.
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: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 28-AS-20210302095454
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ARCADIA GARDENS RETIREMENT HOTEL
FACILITY NUMBER: 197606145
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
12/21/2023
Section Cited
CCR
87468.1(a)(8)
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87468.1 Personal Rights of Residents in All Facilities.
(a)(8) To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs.
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Licensee/ Administrator agrees to conduct in service training to staff on regulation 87468.1 and how to properly inform residents and their authorized representatives of residents' change in condition.
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Based on interviews and record reviews, Administrator failed to notify resident#1's authorized representative of change in condition, which poses a potential health, safety, or personal rights risk to persons in care.
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Licensee agrees to submit a written statement on how this deficiency will be corrected by 12/21/23. Additionally, Licensee will submit proof of staff training which includes staff signatures and dates by 1/3/23.
Deficiency Dismissed
Type B
12/21/2023
Section Cited
CCR
87405(d)(1)
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87405 Administrator - Qualifications and Duties
(d)(1) Knowledge of the requirements for providing care and supervision appropriate to the residents.

This requirement was not met by evidence of:
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Administrator agrees to submit a written plan on how this deficiency will be corrected by 12/21/23.
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Based on interviews and record reviews, Administrator failed to provide proper care to resident#1who had pressure injuries and changed in condition, which poses a potential health, safety, or personal rights risk to persons 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: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6