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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602098
Report Date: 10/02/2019
Date Signed: 07/02/2021 11:57:11 AM



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
09/27/2019 and conducted by Evaluator Juan Miramontes
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20190927134728
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: 85DATE:
10/02/2019
UNANNOUNCEDTIME BEGAN:
08:23 AM
MET WITH:Administrator, Virgilio AgasTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Facility failed to keep accurate records.
INVESTIGATION FINDINGS:
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13
***This report serves as an amendment and supersedes the original complaint investigation report created on 10/02/2019 for the allegation “Residents are not being met due to facility being short staff “ but the result of the finding for “Facility failed to keep accurate records” continued to remain the same***

Licensing Program Analyst (LPA) Christine Wong conducted a subsequent complaint visit to the above facility and met with receptionist Giselle Provencio and administrator Virgilio Agas explained the reason of the visit.

Investigation consisted of the following: LPA Miramontes conducted an initial 10 days visit and delivered finding on 10/2/20219. LPA obtained copy of current copies of the current resident registry and personnel roster. Reviewed the facility hospice list and home health services list, reviewed the facility record files for residents #1-#8 (R1-R8), reviewed the personnel record files for staff #1-#4 (S1-S4) and facility personnel schedule. (See LIC9099C for continuation)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 980-4926
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2021
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 5
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
09/27/2019 and conducted by Evaluator Juan Miramontes
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20190927134728

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: DATE:
10/02/2019
UNANNOUNCEDTIME BEGAN:
08:23 AM
MET WITH:Administrator-Virgillo AgasTIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Residents needs are not being meet due to facility being short staff.
Residents are not being provided adequate food service.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
***This report serves as supersedes the original complaint investigation report created on 10/02/2019 for the allegation “Residents are not being met due to facility being short staff “ but the result of the finding for “Facility failed to keep accurate records” and "Residents are not being provided adequate food service continued to remain the same***

Licensing Program Analyst (LPA) Christine Wong conducted a subsequent complaint visit to the above facility and met receptionist Giselle Provencio and administrator Virgilio Agas and explained the reason of the visit.

Investigation consisted of the following: LPA Miramontes conducted an initial 10 days visit and delivered finding on 10/2/20219. LPA obtained copy of current copies of the current resident registry and personnel roster.
(See LIC9099C for continaution)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 980-4926
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20190927134728
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 RETIREMENT VILLAGE
FACILITY NUMBER: 198602098
VISIT DATE: 10/02/2019
NARRATIVE
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Reviewed the facility hospice list and home health services list, reviewed the facility record files for residents #1-#8 (R1-R8), reviewed the personnel record files for staff #1-#4 (S1-S4) and facility personnel schedule. LPA Miramontes interviewed Lourdes Garcia, Executive Director, S1-S4 and R1-3. On 05/28/21, LPA Wong also reviewed seven (7) residents (R1- R7) medication administration record (MARs). LPA also obtained additional payroll information for June to October 2019.

Investigation revealed of the following: Allegation#1” Residents needs are not being met due to facility being short staff.” LPA interviewed residents and staff, and all denied there’s a short staff in the facility. Residents all reported staff can meet their needs. Staff reported they always have full staff and actively hiring.

Allegation#2 "Residents are not being provided adequate food service." LPA Miramontes observed that there was sufficient amount of food for the amount of residents being served. Schedule of food servers was sufficient in number for the amount of residents being served. LPA Wong also there's sufficient food for two days perishable and seven days non-perishable in the facility. LPA Wong also interviewed residents and reported food is always sufficient in the facility.

Based on the additional interviews conducted, observation and record review, Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit Interview Conducted. A copy of the report and appeal right was provided to Administrator Virgilio Agas, .
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 980-4926
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 28-AS-20190927134728
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 RETIREMENT VILLAGE
FACILITY NUMBER: 198602098
VISIT DATE: 10/02/2019
NARRATIVE
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LPA Miramontes interviewed Lourdes Garcia, Executive Director, S1-S4 and R1-3. On 05/28/21, LPA Wong also reviewed seven (7) residents (R1- R7) and reviewed the medication administration record (MARs)

Investigation revealed of the following: Allegation “Facility failed to keep accurate records.” LPA reviewed 7 residents file for medication administration record (MARs) and all files are either missing staff signature or medication record are not updated on file. Staff admitted they did not sign which supposed to and they did not follow up with the pharmacy.

Based on the additional interviews which were conducted and record review, 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, Chapter 8 is being cited on the attached LIC9099D.

Exit Interview conducted. Copy of the report and appeal right was provided to the Administrator Virgilio Agas
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 980-4926
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20190927134728
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 RETIREMENT VILLAGE
FACILITY NUMBER: 198602098
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/17/2020
Section Cited
CCR
87506(a)
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87506 (a) Resident Records - The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency.
This requirement was not met as evidenced by:
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Licensee to ensure that facility recrod files are current and to assign or designate staff to monitor and provide feedback as to what has been accomplished for the week and by whom. Provide LPA with a Action Plan on how adminsitrator will accomplish these goals by POC due date via email or fax
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LPA's review of resident records that did not contain current updated files which included medication administration records and by disclosure by staff that documentation needs to be filed and is not current.
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CCR
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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: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 980-4926
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5