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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609899
Report Date: 07/21/2022
Date Signed: 07/21/2022 11:52:16 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/14/2022 and conducted by Evaluator Melissa Ruiz
COMPLAINT CONTROL NUMBER: 31-AS-20220714130059
FACILITY NAME:ARCADY VILLAFACILITY NUMBER:
197609899
ADMINISTRATOR:CAJAYON, JOJOFACILITY TYPE:
740
ADDRESS:44334 LIVELY AVETELEPHONE:
(818) 913-2188
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY:6CENSUS: 6DATE:
07/21/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Jojo CajayonTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Sharp objects were not kept in a safe and locked place.
Hazardous chemicals were not kept in a safe and locked place.
Medications were not kept in a safe and locked place.
Facility had spoiled food.
Facility staff did not follow proper Covid-19 screening protocols.
Facility staff did not follow proper Covid-19 masking protocols.
Facility restroom was not equipped with proper hygiene supplies.
INVESTIGATION FINDINGS:
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On 7/19/22 at 10:30 a.m. Licensing Program Analysts (LPAs) Melissa Ruiz and Shira Stamps arrived at the facility to conduct an unannounced complaint investigation. Upon arrival, LPA was greeted by staff (S1) and allowed entrance to the facility. LPA later met with Administrator Jojo and an entrance interview was conducted, the purpose of this visit was explained.

Upon arrival and entrance, LPAs were screened for infection control. S1 contacted the Administrator Jojo. LPA spoke to the Administrator and Administrator stated he was a two-hour drive and designates staff Jeni to sign this report. An entrance interview was conducted over the phone.

Sharp objects were not kept in a safe and locked place.
Hazardous chemicals were not kept in a safe and locked place.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa RuizTELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022
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 4
Control Number 31-AS-20220714130059
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ARCADY VILLA
FACILITY NUMBER: 197609899
VISIT DATE: 07/21/2022
NARRATIVE
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A physical plant tour was conducted from 10:25 – 10:45 a.m. and LPAs observed a pair of scissors to be accessible to residents in care in the kitchen sink. Additionally, LPAs observed a laundry room in the hall, in which they key is kept hanging next to the door. Based on LPAs observation, these allegations are substantiated at this time.

Medications were not kept in a safe and locked place.
Facility had spoiled food.
Facility staff did not follow proper Covid-19 screening protocols.
Facility staff did not follow proper Covid-19 masking protocols.
Facility restroom was not equipped with proper hygiene supplies.

An interview with the Administrator was conducted over the phone at 10:45 a.m. During this interview, the Administrator stated that on various random visits from 2/12/21 – 6/16/22, a credible witness observed the deficiencies listed above and verbal conversations between the Administrator and the credible witness took place. The Administrator indicated that they did in fact had a resident in care that would keep medication on their bedside table in their room, but that the resident is no longer at the facility.

During today’s visit, LPAs did not observe medications accessible to residents in care. Additionally, the Administrator stated that during a visit by the credible witness, they observed expired milk and S1 proceeded to dispose of it. Lastly, the Administrator admitted that during previous visits by the credible witness, staff were not wearing masks or screening visitors. It was also admitted that there were no paper towels in one restroom during one visit. Based on an interview conducted with the Administrator, these allegations are substantiated at this time.

Deficiencies were issued per CA code of Regulations Title 22. See 9099D's included with this report. Appeal rights issued. Report signed and delivered. Exit interview conducted.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa RuizTELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 31-AS-20220714130059
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ARCADY VILLA
FACILITY NUMBER: 197609899
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/23/2022
Section Cited
CCR
87705(f)(1)
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87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
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The Administrator has stated in-house training will be conducted among all staff and a signed written statement will be submitted by the POC due date.
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Based on observation, the Licensee/Administrator did not comply with the section cited above in which LPAs observed scissors in the kitchen accessible to residents in care. This poses an immediate health and safety risk or personal rights risk to resdients in care.
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Type A
07/23/2022
Section Cited
CCR
87705(f)(2)
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87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
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The Administrator stated he will remove the key from the location and has stated in-house training will be conducted among all staff and a signed written statement will be submitted by the POC due date.
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Based on an interview and observation, the Licensee/Administrator did not comply with the section cited above in which the Administrator admitted that a credible witness observed medication accessible to residents in care. LPAs also observed a key to the laundry room which stores chemicals accessible to residents in care. This poses an immediate health and safety risk or personal rights risk to resdients 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: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa RuizTELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 31-AS-20220714130059
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ARCADY VILLA
FACILITY NUMBER: 197609899
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/23/2022
Section Cited
CCR
87470(c)(1)
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87470(c) Infection Control Requirements shall be developed by the licensee... (1) The Infection Control Plan shall include: (F) Staff shall demonstrate knowledge... appropriate to the job assigned and as evidenced by safe and effective job performance.

This requirement was not met as evidenced by:
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Licensee/Administrator has already conducted in house training with all staff. A written statement signed by all staff regarding such training shall be emailed to LPA no later than 7/23/22.
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Based on an interview with the Administrator, the licensee/administrator stated that during a previous visit conducted by the credible witness, staff did not comply with the cited section above by not screening visitors for symptoms of COVID 19 upon entry, staff where not wearing masks, and staff did not replenish the paper towel dispenser in a bathroom which poses and immediate Health and Safety and personal rights risk to persons in care.
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Type B
07/25/2022
Section Cited
CCR
87555(8)
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87555 General Food Service Requirements (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement was not met as evidenced by:
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Licensee/Administrator has already conducted in house training with all staff. A written statement signed by all staff regarding such training shall be emailed to LPA no later than 7/23/22.
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Based on an interview with the Administrator, the licensee/administrator stated that during a previous visit conducted by the credible witness, staff did not comply with the cited section above by retaining spoiled milk after the expiration date.
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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: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa RuizTELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4