197607476-11-14-2022-28-AS-RORN-CLURDR-20221206115619

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607476
Report Date: 11/14/2022
Date Signed: 11/14/2022 02:38:36 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
09/02/2020 and conducted by Evaluator Alma Gonzalez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20200902135824

FACILITY NAME:	VISTA COVE AT ARCADIA		FACILITY NUMBER:	197607476
ADMINISTRATOR:	NOEMI BIELY		FACILITY TYPE:	740
ADDRESS:	601 SUNSET BOULEVARD		TELEPHONE:	(626) 447-0106
CITY:	ARCADIA	STATE: CA	ZIP CODE:	91007
CAPACITY:	0	CENSUS: 0	DATE:	11/14/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Jennifer Lan		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Facility is in disrepair
Facility has mold
Facility is malodorous

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced subsequent complaint visit to gather information pertaining to the above-mentioned allegations. LPA met with Administrative Director/ RN Jennifer Lan and explained the reason for the visit.

The facility is under a new change of ownership, effective 02/17/21; therefore, LPA Gonzalez will mail findings to (former) Licensee.

The investigation consisted of: During the initial visit conducted on 9/4/20, LPA Gonzalez conducted telephone interviews with Executive Director Noemi Biely, and Office Manager Jocelyn Lopez. LPA also conducted a virtual tour via Facetime with Office Manager Jocelyn Lopez. The Virtual Room tour consisted of inspection of facility kitchen, facility dining room, area outside of kitchen, and room #130. LPA collected

(See LIC9099C for continuation)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)981-3982
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:	DATE: 11/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20200902135824

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: VISTA COVE AT ARCADIA	FACILITY NUMBER: 197607476
	VISIT DATE: 11/14/2022

NARRATIVE

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copies of Staff and Resident Rosters. On 11/14/22, LPA interviewed Administrative Director/ RN Jennifer Lan, Staff 1-4 (S1-4), Residents 1-4 (R1-4), conducted a tour of the facility which consisted of inspection of facility lobby, kitchen, dining room, area outside of kitchen, a random selection of resident rooms, Administrative Director's office (which used to be room #130) and Health and Wellness Office. LPA additionally collected copies of Staff and Resident rosters.

Investigation revealed the following: Regarding allegation, Facility is in disrepair, it is alleged that on or about 9/1/20 the facility had plumbing issues, dry rot issues and mold. It is also alleged that the kitchen was being worked on but it has been not been fixed and the work is ongoing and has been worked on for a long time and due to the ongoing work the kitchen staff had to do dishes outside under a cover. Dishes are allegedly being dipped in a sanitizing solution due to the dishwasher being in disrepair. Interviews conducted with 3 out of 4 staff revealed that on or about 9/1/20 the facility was in disrepair. 3 out of 4 staff stated that the facility did have plumbing issues which caused rot and mold and the construction workers had to make holes in the walls of room #130 as well as in the kitchen to fix plumbing issues. 2 out of 4 staff stated that there was mold in Room # 130 but not aware of mold in the kitchen. 3 out of 4 staff stated that the kitchen was being worked on for over 1 month, the dishwasher was in disrepair and staff did have to set up a station outside with three tubs as well as a drying station to be able to clean the dishes. 2 out of 4 staff stated that the 3 tubs consisted of one with hot water to clean the dishes, the second one with a sanitizing solution to ensure that the dishes were properly sanitized and the third tub was used to rinse the dishes. After that process the dishes were transferred to the drying table where they were dried and then transferred inside. This process was in effect for 1-2 months. On 9/4/20, LPA conducted a virtual tour of Room # 130 and observed that there was mold on the wall of the bathroom/ shower area and also observed that the kitchen was under repair and had a section sealed off. The section of the kitchen that was sealed off is where the sink and dishwasher are located. The area was sealed off by a plastic that ran from one side of the wall to the other. LPA asked staff to move the plastic to be able to observe the area and observed that there was a large hole on the floor located in the area of the kitchen that was sealed off by the construction workers/ plumbers. LPA additionally observed the 3 tubs/ canisters that were located outside of the kitchen which were being used as a makeshift sink and drying station.

For allegation, Facility has mold, it is alleged that on or about 9/1/20 the facility had plumbing issues, dry rot issues and mold. The black mold was allegedly in the room directly across from the Health and Wellness

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)981-3982
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:	DATE: 11/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2022

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20200902135824

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: VISTA COVE AT ARCADIA	FACILITY NUMBER: 197607476
	VISIT DATE: 11/14/2022

NARRATIVE

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room/ station as well as in the kitchen. Interviews conducted with 3 out of 4 staff revealed that on or about 9/1/20 the facility was in disrepair. 3 out of 4 staff stated that the facility did have plumbing issues which caused rot and mold and the construction workers had to make holes in the walls of room #130 as well as in the kitchen to fix plumbing issues. 2 out of 4 staff stated that there was mold in Room # 130 and it was severe and the color of the mold was black. 1 out of 4 staff stated that the issue in Room #130 with the mold was immediately taken care of due to the smell that it was causing. On 9/4/20, LPA conducted a virtual tour of Room # 130 and observed that there was mold on the wall of the bathroom/ shower area and observed that the mold was covering a large area of the wall. LPA observed the color of the mold to be black. LPA did not observe any mold in the kitchen.

For allegation, Facility is malodorous, it is alleged that on or about 9/1/20 the facility had plumbing issues, dry rot issues and mold. The black mold was allegedly in the room directly across from the Health and Wellness room/ station as well as in the kitchen. It is also alleged that the sewer water was backing up and was causing smells in the facility. Interviews conducted with 3 out of 4 staff revealed that on or about 9/1/20 the facility was in disrepair. 3 out of 4 staff stated that the facility did have plumbing issues which caused rot and mold and the construction workers had to make holes in the walls of room #130 as well as in the kitchen to fix plumbing issues. 3 out of 4 staff stated that the plumbing issues that the facility was experiencing at that time did cause the facility to smell in the areas that were affected such as in Room # 130 and the kitchen. 2 out of 4 staff stated that there was mold in Room # 130 which caused a strong smell. 1 out of 4 staff stated that even though they used strong cleaning solutions in the bathroom located inside of Room #130 the smell would not go away and was very strong. 1 out of 4 staff stated that the issue in Room #130 with the mold was immediately taken care of due to the smell that it was causing. On 9/4/20, LPA conducted a virtual tour of Room # 130 and observed that there was mold on the wall of the bathroom/ shower area and observed that the mold was covering a large area of the wall. LPA observed the color of the mold to be black. During the tour that was conducted on 11/14/22, LPA observed the facility to be clean, the kitchen to be in full service, Room #130 (which is now Administrative Director's office) including the bathroom to be clean and in good repair. LPA did not smell any smells that can be described as foul or malodorous.

Based on interviews conducted and LPA observations, the preponderance of evidence standard has been met; therefore, the above mentioned allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to Title 22.

Facility has been closed as of 2/17/21. Reason for closure was change of ownership. Exit interview was not conducted, a hard copy of the Complaint Report, Appeal Rights and Civil Penalty will be mailed to Licensee Vista Cove at Arcadia, Inc.'s (#197607476) last known mailing address.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)981-3982
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:	DATE: 11/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2022

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20200902135824

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: VISTA COVE AT ARCADIA	FACILITY NUMBER: 197607476
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/14/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/15/2022 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	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.	1 2 3 4 5 6 7	Licensee to submit written Plan of Correction to ensure the facility is meeting Title 22 Regulation. Licensee to submit a faxed or mailed copy of POC by due date.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: On 9/4/20, LPA conducted a virtual tour of the facility and observed the kitchen was under repair and had a section sealed off where a large whole was observed on the floor. LPA additionally observed 3 tubs/ canisters that were located outside of the kitchen which were being used as a makeshift sink and drying station. This poses an potential health and safety risk to residents in care.	8 9 10 11 12 13 14
Type B 11/21/2022 Section Cited CCR 87303(a)(1)	1 2 3 4 5 6 7	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. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.	1 2 3 4 5 6 7	Licensee to submit written Plan of Correction to ensure the facility is meeting Title 22 Regulation. Licensee to submit a faxed or mailed copy of POC by due date.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: On 9/4/20, LPA conducted a virtual tour of the facility and observed that there was large section of mold on the wall of the bathroom/ shower area of RM #130. Interviews with 3 out of 4 staff revealed that there were strong smells at the facility due to the plumbing issues and the mold in Rm #130. This poses an potential health and safety risk to residents in care.	8 9 10 11 12 13 14

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: David Sicairos	TELEPHONE: (323)981-3982
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:	DATE: 11/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2022

LIC9099 (FAS) - (06/04)

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