198602098-4-13-2022-28-AS-MVAO-CEJQ5H-20220518115159

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602098
Report Date: 04/13/2022
Date Signed: 04/13/2022 06:33:08 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,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/01/2020 and conducted by Evaluator Antonia Alvizar

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20200701154007

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: 74	DATE:	04/13/2022
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Virgilio Agas		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff engaged in an argument with resident.
Staff forcefully removed a key chain from resident.

INVESTIGATION FINDINGS:

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On 04/13/2022 Licensing Program Analyst (LPA) Antonia Alvizar and Licensing Program Manager (LPM) Ulysses Coronel conducted a subsequent complaint investigation on a complaint made against the former licensee. LPA Alvizar and LPM Coronel met with administrator Virgilio Agas who was employed as the incoming administrator during the time of the complaint allegations.

The investigation consisted of the following: On 07/10/2020 LPA Bonnie Tao conducted a telephone interview with administrator Lourdes Garcia, a video call interview with resident R1 and obtained staff and resident records. On 04/13/2022 LPA Alvizar and LPM Coronel interviewed Administrator Agas, 4 out of 74 residents and 4 staff, reviewed resident, staff, and facility records and conducted a tour of the facility.

Report Continues, please see LIC 9099- C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Antonia Alvizar	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2022

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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Control Number 28-AS-20200701154007

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: ARCADIA RETIREMENT VILLAGE	FACILITY NUMBER: 198602098
	VISIT DATE: 04/13/2022

NARRATIVE

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The investigation revealed the following: Regarding the allegation “Staff engaged in an argument with resident.” During interviews conducted, 4 out of 4 residents disagreed with the allegation. On 04/13/2022 resodent R1 stated , “The staff they are cool, I just don’t want anyone taking my key’s and my bag from me.” Resident R4 stated “It’s actually the residents who keeps arguing with staff." 5 out of 5 staff interviewed disagreed with the allegation staff S1 stated “That never happens, we always respect the residents here". Regarding the allegation “Staff engaged in an argument with resident.” “Although the allegation may have happened or is valid, there is not preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.”

Regarding the allegation: “Staff forcefully removed a key chain from resident.” During interviews conducted, 2 out of 4 residents agreed with the allegation, on 04/13/2022 resident R2 stated “When I moved into this room they took some items from me, but when I reported it to the administrator they returned them.” 2 out of 4 residents disagreed with the allegation, on 04/13/2022 resident R1 stated “The staff they are cool, I just don’t want anyone taking my key’s and my bag.” 5 out of 5 staff interviewed disagreed with the allegation staff S1 stated “We never do that, because of our level of training, we do not forcefully take things from residents”. Regarding the allegation “Staff forcefully removed a key chain from resident.” “Although the allegation may have happened or is valid, there is not preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.”

No deficiencies cited. An exit interview was conducted and a copy of this report was provided to Vurgilio Agas and mailed to former licensee Dr. Mohamed Seilami.

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Antonia Alvizar	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2022

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20200701154007

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: ARCADIA RETIREMENT VILLAGE	FACILITY NUMBER: 198602098
	VISIT DATE: 04/13/2022

NARRATIVE
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SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Antonia Alvizar	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2022

LIC9099 (FAS) - (06/04)

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