198602098-3-3-2023-28-AS-FFIS-CPRR63-20230309114402

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602098
Report Date: 03/03/2023
Date Signed: 03/03/2023 03:14:46 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 Bonnie Tao

COMPLAINT CONTROL NUMBER: 28-AS-20201008164737

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: 79	DATE:	03/03/2023
		UNANNOUNCED	TIME BEGAN:	08:20 AM
MET WITH:	Gil Agas, administrator		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff was not refilling resident’s medication prescription
Staff was not attending to resident’s injury as needed
Staff was not returning resident’s belongings

INVESTIGATION FINDINGS:

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

***This report serves as an amendment and supersedes the complaint investigation reports created on 06/22/22 and 10/16/20. Findings remain the same as unsubstantiated.***

Licensing Program Analyst (LPA) Tao conducted a subsequent unannounced complaint investigation for the allegations listed above today. LPA met Administrator, Gil Agas and explained the purpose of today's visit.

On 10/16/20, LPA Tao conducted an initial investigation visit telephonically due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures. LPA obtained staff roster, resident roster, Resident #1’s (R1) Physician report, R1’s Identification and Emergency information, R1’ Pre-placement appraisal, R1’s Functional Capability Assessment, R1’s incident report (dated 8/23/20), Physician's Telephone Orders (dated 06/25/20 & 06/29/20), R1's narrative notes (dated 6/29/2020), R1's Resident Personal, Property and Valuable, Post R1's Discharge Plan of Care, Home Health Agency Notes, Medication Administration Record (MAR), and Change of Dressing (toe) Schedule. (-continued in LIC 9099 C-)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023

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 3

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: 03/03/2023

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

***This report serves as an amendment and supersedes the complaint investigation report created on 06/22/22 and 10/16/20. Findings remain the same as unsubstantiated. ***

LPA Tao interviewed staff#1 (S1), resident#1 (R1) and resident#2 (R2) telephonically.

On 06/22/22, LPA Elizabeth Ceniceros conducted a subsequent visit. During the visit, LPA Ceniceros reviewed resident#1’s records, Home Health Agency Notes, Medication Administration Record (MAR), and Change of Dressing (toe) Schedule. LPA delivered findings.

On 03/03/23, LPA Tao conducted another subsequent visit today. During the visit, LPA obtained copies of staff and resident rosters, interviewed residents from resident #3 (R3) through resident #7 (R7), reviewed resident #1 (R1) records, and delivered findings. Investigation consisted of the following: interviews of staff #1 (S1) interviews of residents from Resident#1 (R1) through Resident#7 (R7); reviewed resident#1’s record reviews, and a facility tour.

In regard of the allegation, ‘staff was not refilling residents medication prescription” it was alleged that staff did not refill R1’s narcotic medication timely. The investigation revealed the following: LPA interviewed resident#1, resident said staff did not refill R1’s medication timely. Six (6) out of seven (7) residents interviewed could not corroborate the allegation. All staff interviewed denied the allegation. Per LPA Ceniceros’ file review revealed that Resident #1’s narcotic medication refill required a physician’s approval (triplicate order) for a narcotic medication. Due to the requirement of having a triplicate order - three (3) doctors’ approvals, this narcotic medication was delayed due to Med Techs contact the pharmacy who request’s authorization from the resident’s doctor. Once the narcotic medication has been refilled, it’s delivered to the facility. Staff had responded to R1’s medication needs timely and requested authorizations to doctors to refill the resident's narcotic medication. Therefore, there is not preponderance evidence to prove staff was not refilling resident’s medication prescription.

In regard of the allegation, “staff was not attending to resident’s injury as needed,” it was alleged that staff did not properly attend to R1’s toe infection on R1’s left foot. The investigation revealed the following: LPA interviewed resident#1, resident said staff did not attend R1’s toe infection. Six (6) out of seven (7) residents interviewed could not corroborate the allegation. All staff interviewed denied the allegation.
(-continued in LIC 9099 C-)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

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: 03/03/2023

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

***This report serves as an amendment and supersedes the complaint investigation report created on 06/22/22 and 10/16/20. Findings remain the same as unsubstantiated. ***

Per LPA Ceniceros’ file review revealed that Resident #1’s diagnosis of having a very poor circulation to bilateral lower extremity (BLE) left toe. Based on medical information provided by home health skilled nurses, home health ordered changing of the resident’s dressing and followed up treatment with R1’s left foot treatments daily. Staff #3 & Staff #4 (Med Techs) attempted to assist to change R1’s wound dressing; however, R1 refused to have R1’s 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 R1’s 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. In the meanwhile, R1 was being followed up by home health nurses. Therefore, there is not preponderance evidence to prove staff was not attending to resident’s injury as needed.

In regard of the allegation, “staff was not returning residents belongings,” it was alleged that staff did not return R1’s clothes. The investigation revealed the following: LPA interviewed resident#1, resident said staff did not return R1’s clothes to resident. Six (6) out of seven (7) residents interviewed could not corroborate the allegation. All staff interviewed denied the allegation. Staff interviewed revealed that residents’ clothes were misplaced in their room rather than missing or not returning to residents. Therefore, there is not preponderance evidence to prove staff was not returning residents belongings.

Although the allegations 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 is UNSUBSTANTIATED.

No deficiencies are being cited according to California Code of Regulations, Title 22, Division 6, Chapter 8.

An exit interview was conducted with Administrator, Gil Agas. A hard copy of this report was provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3