198602098-1-26-2023-28-AS-FFIS-CPRV9H-20230309151423

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602098
Report Date: 01/26/2023
Date Signed: 01/26/2023 11:27:43 AM

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
10/01/2020 and conducted by Evaluator Valeria Maldonado

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20201001140916

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: 80	DATE:	01/26/2023
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Gil Agas- Administrator		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Facility staff did not follow residents wound care plan.
Facility staff did not dispense resident's medication as prescribed.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) V. Maldonado made a subsequent unannounced visit at the facility for the purpose of investigating the above-mentioned allegations. LPA Maldonado met with Administrator Gil Agas and explained the purpose for the visit.

On 1/13/23, LPA Maldonado made a subsequent visit for the purpose of investigating the allegations. LPA met with Gil Agas and explained the purpose of the visit. During the visit, LPA obtained a copy of the resident/staff roster and the following documents for Residents# 1-2, 8-9, and 11-14 (R1-R14): Physicians Report, Pre-Placement and Current Appraisal, and Needs and Services Plan, as they were not previously available for review. LPA also obtained incident reports and communications with Administrator for R1 and Move-Out Policy, Physician's Report, incident reports, physician's telephone orders, Facility Narrative Reports, Physician's Order Reports, and Medication Administration Logs for R2. LPA Maldonado interviewed Staff #2-3, and 7-9 (S2-S9) and R1-R2, R8-9, and R11-14.
(Report Continued on LIC9099-C...)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023

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-20201001140916

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: 01/26/2023

NARRATIVE

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On 10/08/2020, LPA B. Tao made an initial visit, which was conducted telephonically due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures. During the visit, LPA Tao conducted a telephone interview with Staff #1. The LPA obtained a staff roster and resident roster. LPA requested Physician's Report, Preplacement Appraisal- LIC 603, Appraisal- LIC 603, Needs and Services Plan- LIC 625 for Resident #1 to Resident # 10. LPA requested incident reports of Resident #1 and Resident #2. For Staff#1 to Staff # 7's records, LPA requested In-service training logs, Administrator certificate and write-up/complaint, if any.
On 1/26/23, LPA conducted an interview with the home health nurse (RN) responsible for R1's wound care.
The investigation revealed the following:
Regarding allegation: Facility staff did not follow residents wound care plan.
It is alleged that facility staff did not follow the wound care plan for R1 that was in place from the home health agency, causing R1's wound to become infected and sent to hospital due to infection. Per interview with R1, R1 could not recall which facility staff assisted with wound care, but stated that staff were not cleaning their wound daily. Per interviews conducted with staff, S7 stated that R1 was supposed to receive daily wound care at the facility that required daily cleaning of the wound and changing the dressings; however, R1 refused changes. R1's wound care plan indicated that R1 was prone to re-infection if not treated. Per home health communication notes dated 8/20/20 and 8/17/20, R1 was continuously refusing visits from the agency for wound care and follow-ups and all parties were notified. R1's physician was also made aware of possible early discharge from the agency's care. Per interview conducted with RN, it was stated that RN witnessed R1 constantly refusing wound care and received recurring notice from facility staff that to R1 was refusing wound care on day's that home health was not there. This allegation is unsubstantiated.
Regarding allegation: Facility staff did not dispense resident's medication as prescribed.
It is alleged that upon admission to the facility, facility staff took 8-10 days to provide R1 with their prescribed pain medications and was advised to take a different medication. Per interview with R1, it was stated that facility staff did not give R1 the pain medication R1 was prescribed prior to being admitted to this facility. Per home health notes, R1 continued with the previously prescribed medications and no notes are indicated of R1 not receiving medication. (5) of (5) staff interviewed stated they have no knowledge of R1 not receiving their medication as prescribed. (5) of (8) residents state to not have issues with receiving any medications. This allegation is unsubstantiated.
Per California Code of Regulations, Title 22, no deficiencies were observed or cited.

An exit interview was conducted with administrator Gil Agas and copy of this report was provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023

LIC9099 (FAS) - (06/04)

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