198602098-10-16-2020-28-AS-FFIS-CPRR65-20230309114405

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602098
Report Date: 10/16/2020
Date Signed: 10/16/2020 05:44:55 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:	149	CENSUS: 89	DATE:	10/16/2020
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Administrator, Lourdes Garcia		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff not returning residents belongings.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tao initiated a complaint investigation for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Administrator, Staff #1.

LPA Tao spoke with Administrator and conducted telephone interview with Staff #2, Resident # 1 and Resident #2. The LPA obtained copies of Resident roster, Staff 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 6/25/20, R1's narrative notes 6/29/2020, R1's Resident Personal, Property and Valuable, and Post R1's Discharge Plan of Care.

(- continued in LIC 9099C)

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: 10/16/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2020

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-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: 10/16/2020

NARRATIVE

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LPA requested R1’s Medication Administration Record (MAR), document that log R1's wound dressing changing, document that showed R1's Medication orders/ refills, and R1's pharmacy contact information.

The investigation revealed the following:

The details of this allegation states that some R1's belongings were missing when R1 moved to another facility.

Based on interviews conducted, the statements provided were inconsistent regarding the allegation listed above. There is insufficient evidence to support the allegation that facility failed to return resident's personal belongings. According to the Administrator, resident's belongings were returned to resident. According to R1, resident got the belonging back and only some clothes were missing. Those clothes were unidentifiable.

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 is Unsubstantiated.

A telephonic exit interview was conducted with Administrator, and a hard copy was provided via email for signature.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 10/16/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2020

LIC9099 (FAS) - (06/04)

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