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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602098
Report Date: 08/28/2020
Date Signed: 08/31/2020 11:16:20 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
08/21/2020 and conducted by Evaluator Bonnie Tao
COMPLAINT CONTROL NUMBER: 28-AS-20200821120543
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:
08/28/2020
UNANNOUNCEDTIME BEGAN:
09:58 AM
MET WITH:Administrator, LOURDES GARCIATIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Due to lack of adequate supervision, resident has eloped from the facility on multiple occasions.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Tao conducted an initial 10-day visit regarding the investigation in order to deliver finding on the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Licensee, staff and residents. LPA discussed the purpose of the investigation with Administrator Lourdes Garcia.

The investigation consisted of a virtual tour for health and safety check, interviews were conducted with Resident #1 and with Staff #1 to Staff #5. LPA reviewed special incident reports; Resident #1(R1)’s Needs and Services plan; R1’s Resident Appraisal; R1’s Administrator note dated 07/28/20, and R1’s Physician Report.

Regarding allegation, the investigation revealed that the resident would walk away from the facility. Facility reported R1’s behaviors in incident reports dated 08/10/20 and 07/27/20. (See LIC 9099 C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2020
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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