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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602098
Report Date: 06/22/2022
Date Signed: 06/22/2022 11:00:35 AM

Substantiated


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
06/25/2020 and conducted by Evaluator Elizabeth Ceniceros
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20200625090701
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:0CENSUS: 70DATE:
06/22/2022
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Administrator, Virgilio AjasTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Facility bathrooms are in disrepair.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Retired Annuitant (RA) Elizabeth Ceniceros made an unannounced visit to the facility and was greeted by Administrator (Virgilio Ajas). The purpose of this visit is to deliver the findings pertaining to the above-mentioned allegation.

A virtual 10-Day visit was conducted by LPA Bonnie Tao on 07/06/20 (via telephonically) with Asst. Administrator (A2: Vigillio Ajas) due to the situation surrounding the Coronavirus Disease 2019 (COVID-19) and to implement mitigation measures. During the virtual, video conference call with Asst. Administrator Ajas, LPA Tao conducted a virtual tour of the facility’s physical plant. LPA interviewed Administrator (Lourdes Garcia), one (1) staff member, and one (1) resident in care. LPA obtained copies of the Residents Roster, LIC 500, Staff Work Schedules (July 2020), and Service Logs (06/23/20).
Regarding Allegation #3: this investigation revealed that the facility’s bathroom (located in the dining room area), it was observed that the light switch was inoperable; and, it was too dark for the residents to use the bathroom.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Araceli RamirezTELEPHONE: (323) 980-4925
LICENSING EVALUATOR NAME: Elizabeth CenicerosTELEPHONE: (916) 264-1579
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2022
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 5
Control Number 28-AS-20200625090701
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: 06/22/2022
NARRATIVE
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Based on the evidence gathered and interviews conducted and records reviewed, the preponderance of evidence standard has not been met; therefore, the allegation of PHYSICAL PLANT: Facility bathrooms are in disrepair is found to be SUBSTANTIATED.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiency has been observed and a citation issued (ref. LIC 9099D).

An exit interview has been conducted and a copy of the Complaint Report and Appeal Rights were provided to Administrator (Virgilio Ajas).

SUPERVISOR'S NAME: Araceli RamirezTELEPHONE: (323) 980-4925
LICENSING EVALUATOR NAME: Elizabeth CenicerosTELEPHONE: (916) 264-1579
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20200625090701
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: 06/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/29/2022
Section Cited
CCR
87303(a)(d)
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Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (d) There shall be lamps or light appropriate for the use of each room and sufficient to ensure the
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Licensee/Administrator shall read Title 22, Section 87303 “Maintenance and Operation” and send a written statement to CCLD by the POC date that Licensee/Administrator will ensure maintenance services and procedures for the safety and well-being of residents, employees, and visitors. The plan of correction is due to CCLD/El Segundo ASC
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(Cont) comfort and safety of all persons in the facility. The standard of evidence was not met based on the facility’s bathroom (located in the dining room area), the light switch was inoperable; and, it was too dark for the residents to use the bathroom.
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(Cont) Office no later than 06/29/22.
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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: Araceli RamirezTELEPHONE: (323) 980-4925
LICENSING EVALUATOR NAME: Elizabeth CenicerosTELEPHONE: (916) 264-1579
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2022
LIC9099 (FAS) - (06/04)
Page: 3 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
06/25/2020 and conducted by Evaluator Elizabeth Ceniceros
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20200625090701

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:0CENSUS: 70DATE:
06/22/2022
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Administrator, Virgilio AjasTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Resident fell while in care resulting in minor injury.
Staff did not provide assistance to resident in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Retired Annuitant (RA) Elizabeth Ceniceros made an unannounced visit to the facility and was greeted by Administrator (Virgilio Ajas). The purpose of this visit is to deliver the findings pertaining to the above-mentioned allegation.

A virtual 10-Day visit was conducted by LPA Bonnie Tao on 07/06/20 (via telephonically) with Asst. Administrator (A2: Vigillio Ajas) due to the situation surrounding the Coronavirus Disease 2019 (COVID-19) and to implement mitigation measures. During the virtual, video conference call with Asst. Administrator Ajas, LPA Tao conducted a virtual tour of the facility’s physical plant. LPA interviewed Administrator (A1: Lourdes Garcia), one (1) staff member, and one (1) resident in care. LPA obtained copies of the LIC 500, Staff Work Schedules (July 2020), and Residents' roster. LPA requested pertinent documentation: Unusual Incident/Injury Report (06/23/20); Resident #1's Pre-placement Appraisal Information (04/02/19), Physician's Report (04/29/19), Identification and Emergency Information, Appraisal/Needs and Services Plan (09/10/19).
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Araceli RamirezTELEPHONE: (323) 980-4925
LICENSING EVALUATOR NAME: Elizabeth CenicerosTELEPHONE: (916) 264-1579
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2022
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-20200625090701
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: 06/22/2022
NARRATIVE
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Regarding Allegation #1: this investigation revealed that Resident (#1) sustained an unwitnessed fall on 06/23/20 in its bathroom. A review of the Unusual Incident/Injury Report (dated 06/23/20) documented that Staff #3 (S3: Med Tech) attended to R1’s call light. Upon arrival, S3 observed R1 on the bathroom floor and found no bruising, redness or skin tear in the affected area. R1 was able to walk without complain of pain and range of motion to bilateral extremities were intact. R1 refused to be sent to the hospital for further evaluation. A review of R1’s medical report and assessments are as follows: Pre-placement Appraisal Information, documents the resident does not require assistance with its functional capabilities. Physician’s Report, does not document that the resident is a fall risk. Appraisal/Needs and Services Plan, does not document R1 has difficulties with physical development.

Based on the evidence gathered and interviews conducted and records reviewed, 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 of NEGLECT/LACK OF CARE: Resident fell while in care resulting in minor injury is found to be UNSUBSTANTIATED.

Regarding Allegation #2: this investigation revealed that a review of the facility’s Service Log (dated 06/23/20), documented that Resident #1 (R1) was monitored by Staff #4 (Caregiver – A.M.): at 6:30 a.m. for 2-hour check; at 9:00 a.m. for 2-hour check; at 11:00 a.m. for 2-hour check; at 1:00 p.m. for 2-hour check. R1 was monitored by Staff #5 (Med Tech – P.M.): at 2:30 p.m. for 2-hour check; at 5:00 p.m. for 2-hour check; at 7:00 p.m. for 2-hour check; at 9:00 p.m. for 2-hour check. R1 was monitored by Staff #6 (Med Tech – NOC): at 10:30 p.m. for 2-hour check; at 1:00 a.m. for 2-hour check; 3:00 a.m. for 2-hour check; 5:00 a.m. for 2-hour check; 6:30 a.m. for 2-hour check. A review of the Unusual Incident/Injury Report (dated 06/23/20) documented that Staff #3 (S3: Med Tech) attended to R1’s call light and assessed the resident who refused to be sent to the hospital for further evaluation.

Based on the evidence gathered and interviews conducted and records reviewed, 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 allegation of NEGLECT/LACK OF CARE: Staff did not provide assistance to resident in a timely manner is found to be UNSUBSTANTIATED.

An exit interview has been conducted and a copy of the Complaint Reports were provided to Administrator (Virgilio Ajas).

SUPERVISOR'S NAME: Araceli RamirezTELEPHONE: (323) 980-4925
LICENSING EVALUATOR NAME: Elizabeth CenicerosTELEPHONE: (916) 264-1579
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5