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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 12:28:53 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
10/08/2020 and conducted by Evaluator Elizabeth Ceniceros
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20201008164737
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:
11:00 AM
MET WITH:Administrator, Virgilio AjasTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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9
Staff not attending to residents injury as needed.

Staff not refilling residents medication prescription.
INVESTIGATION FINDINGS:
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Licensing Program Analyst/Retired Annuitant (LPA/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 allegations.

An Initial 10-Day virtual visit was conducted by LPA Bonnie Tao on 10/16/20 (via telephonically) with Administrator (Lourdes Garcia) due to the situation surrounding the Coronavirus Disease 2019 (COVID-19) and to implement mitigation measures. During the virtual, video conference call with Administrator Garcia, LPA Tao conducted a virtual tour of the facility’s physical plant. LPA interviewed one (1) staff and two (2) residents. In addition, LPA requested pertinent documents: Staff & Residents' rosters; Resident #1’s Physician Report, Identification and Emergency Information, Pre-placement Appraisal, Functional Capability Assessment, Safeguard for Property/Valuables, and Unusual Injury/ Incident Report (08/23/20); Physician's Telephone Orders (06/25/20 & 06/29/20), Narrative Notes (06/29/20), and Post Discharge Plan of Care, Home Health Agency Notes, Medication Administration Record (MAR), and Change of Dressing (toe) Schedule.
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: 1 of 2
Control Number 28-AS-20201008164737
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 was discharged from a skilled-nursing facility (SNF) and admitted to the facility on 06/29/20 with a diagnosis of very poor circulation to bilateral lower extremity (BLE) left toe. Left leg/left foot – with mounds being treated by home health. Resident #1’s physical limitation: unable to ambulate due to peripheral vascular disease (PVD) exacerbation and mounds to left foot, with multiple toes acquired absence from symptoms due to poor circulation. Based on medical information provided by home health skilled nurses, home health ordered changing of the resident’s dressing every other day and then changing daily; and, home health followed up with left foot treatments. Staff #3 & Staff #4 (Med Techs) were doing the wound dressing; however, Resident #1 refused to have her wound dressing changed by the Med Techs. Administrator contacted Resident #1’s doctor who requested that the resident be sent to the hospital. Resident #1 refused to go to the hospital. Resident #1’s doctor came to evaluate its foot and decided to send the resident to the hospital on 08/23/20 for wound re-evaluation due to signs of circulation problems and infection – despite the resident being followed up by home health nurses.

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: Staff not attending to residents injury as needed is found to be UNSUBSTANTIATED.

Regarding Allegation #2: this investigation revealed that Resident #1 was prescribed a narcotic medication. A review of Resident #1’s Medication Administration Record (June 2020 – August 2020) documented that Resident #1’s narcotic medication refill required a physician’s approval (triplicate order) for a narcotic medication. There are times that this narcotic medication is delayed due to being a triplicate order - three (3) approvals. Med Techs contact the pharmacy who request’s authorization from the resident’s doctor. Once the narcotic medication has been filled, it’s delivered to the facility; and, it all depends on how quick the physician responds to a request for authorization to refill the resident's narcotic medication.

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 MEDICATION: Staff not refilling residents medication is found to be UNSUBSTANTIATED.

An exit interview has been conducted and a copy of the Complaint Report was 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 2