198602098-4-16-2022-28-AS-MVAO-CDNKTB-20220420081052

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602098
Report Date: 03/19/2022
Date Signed: 04/16/2022 10:11:50 PM

Unsubstantiated

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
10/20/2020 and conducted by Evaluator Nicol Wesley

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20201020161202

FACILITY NAME:	ARCADIA RETIREMENT VILLAGE		FACILITY NUMBER:	198602098
ADMINISTRATOR:	LOURDES GARCIA		FACILITY TYPE:	740
ADDRESS:	607 WEST DUARTE ROAD		TELEPHONE:	(626) 447-6070
CITY:	ARCADIA	STATE: CA	ZIP CODE:	91007
CAPACITY:	0	CENSUS: 0	DATE:	03/19/2022
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:			TIME COMPLETED:	03:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident developed pressure injury while in care.
Staff did not seek medical attention in a timely manner.
Staff failed to meet resident's needs.
Staff did not safeguard resident's belongings.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Nicol Wesley initiated a subsequent complaint investigation for the allegations listed above

The investigation consisted of the following: On 10/29/2020 LPA Wesley conducted a telephonic interview and requested a copy of: staff roster, resident roster, physician's report, and the following documents for resident #1: Emergency identification page(ID Page), needs and service plan, Pre-placement appraisal, Medication log(MAR) for July/August 2020, client/resident personal property and valuables(LIC 621) to be faxed/emailed by 10/30/20. LPA Wesley also interviewed the Administrator Lourdes Garcia regarding the above mentioned allegations and interviewed resident #1.

Regarding allegation: Resident developed pressure injury while in care, Staff failed to meet resident's needs, and Staff did not seek medical attention in a timely manner. During the investigation, LPA reviewed resident #1
Continued on LIC 9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Nicol Wesley	TELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2022

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 2

Control Number 28-AS-20201020161202

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: 03/19/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

file (R1) that revealed that on 06/25/2020 prior to residing at Arcadia Retirement Village the facility, R1 was being treated for a left foot fungal rash/wound on their left foot and toes and was prescribed medication and treatment instructions for 21 days, and was allowed to be discharged to Arcadia Retirement Village on 6/29/2020. R1 is ambulatory(uses a walker), and is able to communicate their needs. R1's Primary Physician(doctor), authorized/designated a Home Health Nurse to visit the facility several times a week to provide treatment to R1's wound on their left foot which had noted bruising/discoloration and was documented the wound was due to poor circulation, and R1 was also being treated for a fungal rash/wound on their left foot and toes There was no indication that R1 developed a Pressure Injury(PI) while in the facility from 06/29/2020-08/23/2020. On 08/23/2020 the doctor evaluated R1's foot wound and sent them to the hospital for re evaluation and indicated it was due to signs of circulation problems and infection in spite of treatment from the Home Health Nurses. Although the physician had the Home Health providers caring for the residents wounds, there was no indication from the doctor that he wound had developed intro a pressure injury. The doctors notes indicated that R1 had discoloration to their foot due to very poor circulation.

Regarding allegation: Staff did not safeguard resident's belongings. During the investigation, LPA reviewed resident #1 file which included the resident personal property and valuables(LIC 621) that was signed by R1. There were no specific items listed on the LIC 621 form. The LIC 621 form listed: residents clothes(did not specify amount, description, and 1 walker. R1 signed the document upon admission to the facility. During the interview with the assistant administrator Deoso, the resident did not come to the facility with a lot of belongings. On 09/18/2020 R1 authorized Baldwin Gardens to pick up their belongings in which the representative did not do an inventory or list the items they received. The document titled "Move Out Policy" was signed and the facility Administrator documented: "did not do inventory, as Is." The representative signed the document and did not list the items that were retrieved. There was no indicating that R1 had the following items in their room: Oral B electric toothbrush, 3 pairs of black cotton pants, 3 pairs black nylon pants, 3 black tank tops, gray sweater, Maroon sweatpants & top, shower puff, paperwork, pajama top & bottom with heart, and other miscellaneous items. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated.

There are no deficiencies cited.

A copy of this report mailed to the address on file.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Nicol Wesley	TELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2