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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602098
Report Date: 07/22/2020
Date Signed: 07/22/2020 04:00:29 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 RETIREMENT VILLAGEFACILITY NUMBER:
198602098
ADMINISTRATOR:LOURDES GARCIAFACILITY TYPE:
740
ADDRESS:607 WEST DUARTE ROADTELEPHONE:
(626) 447-6070
CITY:ARCADIASTATE: CAZIP CODE:
91007
CAPACITY:149CENSUS: 91DATE:
07/22/2020
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Virgilio AgasTIME COMPLETED:
02:45 PM
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On 07/22/20 at 2:00 pm, Licensing Program Analyst, LPA/Ernand Dabuet initiated a collateral visit. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s visit was conducted telephonically with Virgilio Agas/Assistant Administrator.

LPA explained the purpose of the call was to interview (R1) resident. The board and care facility where the resident formerly resided at Hayworth Terrace has an existing complaint 11-AS-20200713114811 and that LPA is to interview the resident and to gather information. The interview was conducted with the resident with the use of FaceTime application. In addition, LPA requested for a copy of (R1's) admissions agreement to be sent by email before 07/24/20. .

A telephonic exit interview was conducted with Virgilio Agas and a hard copy was provided via email for signature.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5520
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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