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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602098
Report Date: 10/25/2022
Date Signed: 10/25/2022 04:34:23 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
05/20/2020 and conducted by Evaluator Bonnie Tao
COMPLAINT CONTROL NUMBER: 28-AS-20200520082357
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: 82DATE:
10/25/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Gil Agas, AdministratorTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Facility has pests
Facility is in disrepair
Residents are not allowed to use a functioning toilet
Resident is not provided clean linens
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tao conducted unannounced complaint investigation for the allegations listed above today. During today’s visit, LPA met administrator, Gil Agas. LPA explained the purpose of today's visit regarding the above-mentioned allegations.

Investigation consisted of the following: interviews of staff from Staff #1 (S1) through Staff #4 (S4); interviews of residents from resident#1 (R1) through resident #9 (R9); reviews of resident#1’s record and a facility tour. LPA obtained copies of the staff and resident rosters; and resident #1s’ records with relevant information.

The investigation revealed the following:
Regarding the allegation “facility has pests," it was alleged that resident's bathroom and facility’s dining room on the first floor had cockroaches. The investigation consisted of interviews of residents. LPA tried multiple attempts to interview resident#1 via phone calls because resident#1 had transferred to another facility in 2020. All LPA's attempts were failed, and LPA was unable to interview resident#1 due to resident's contact was lost. (-continued in 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: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2022
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-20200520082357
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: 10/25/2022
NARRATIVE
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Resident interviews from R2 through R9 revealed that eight (8) out of nine (9) residents stated resident did not see cockroaches in resident’s bathroom and facility’s dining room on the first floor. Four (4) out of four (4) staff denied the allegation. Staff interviews revealed staff did not observe cockroaches in resident bathroom and facility dining room on the first floor. LPA toured the facility and Room #237. LPA did not observe pests or cockroaches during the visit. Therefore, the investigation revealed resident bathroom and facility’s dining room on the first floor did not have cockroaches.

Regarding the allegation “facility is in disrepair," it was alleged that resident's bedroom blinds was broken. LPA was unable to interview resident #1. Resident interviews from R2 through R9 revealed that eight (8) out of nine (9) residents stated resident's bedroom blinds were in good repair. Four (4) out of four (4) staff denied the allegation. LPA toured room #237 and no blind was broken. Therefore, the investigation revealed resident's bedroom blinds was not broken and in good repair.

Regarding the allegation “residents are not allowed to use a functioning toilet," it was alleged that residents' bathroom on the first floor that residents use had a clogged toilet. LPA was unable to interview resident #1. Resident interviews from R2 through R9 revealed that eight (8) out of nine (9) residents revealed that the toilet in residents' bathroom on the first floor was not clogged. Four (4) out of four (4) staff denied the allegation. LPA toured room #237's bathroom and resident bathroom on the first floor. LPA flushed both toilets and they both were functional. Therefore, the investigation revealed that the toilet in residents' bathroom on the first floor was not clogged and facility was in good repair.

Regarding the allegation “resident is not provided clean linens," it was alleged that residents were not given clean towels to use. LPA was unable to interview resident #1. Resident interviews from R2 through R9 revealed that eight (8) out of nine (9) residents revealed that residents were given clean towels to use. Four (4) out of four (4) staff denied the allegation. LPA observed laundry staff handling laundry, towels and linens. Linens were observed to be clean. Therefore, the investigation revealed that residents were given clean towels to use.

Although the allegation may have happened or is valid, there’s not a preponderance of evidence to prove the alleged violations did or did not occur, therefore, the allegations are UNSUBSTANTIATED

Exit interview conducted and a copy of LIC 9099 report was given to administrator, Gil Agas.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2