198602098-1-28-2023-28-AS-FFIS-CPRV9J-20230309151424

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602098
Report Date: 01/13/2023
Date Signed: 01/28/2023 02:44:52 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
10/01/2020 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: 81	DATE:	01/13/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Gil Agas- Administrator		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Facility staff speak inappropriately to residents.
Facility staff did not allow resident to have a telephone call.
Facility staff threw water in resident's face.
Facility staff do not treat resident with respect.
Facility staff handle resident in a rough manner.
Facility staff did not return resident's personal property upon termination of serivces.

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 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.

(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: 01/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2023

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 5

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: 01/13/2023

NARRATIVE

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During today's visit, LPA Maldonado 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.

The investigation revealed the following:
Regarding allegation: Facility staff speak inappropriately to residents.
It is alleged that the reporting party (RP) overhead a staff at the facility telling R1 in Spanish "Why the fuck" was R1 bothering staff. Per R1, this was a regular occurrence. LPA was unable to interview R1 due to R1 no longer residing at the facility and contact with R1 was unsuccessful. Per interviews conducted, (5) of (8) residents state staff do not speak inappropriately to residents. (5) of (5) staff interviewed stated they do not speak inappropriately to residents and have no knowledge of residents reporting staff were speaking inappropriately to them. This allegation is unsubstantiated.

Regarding allegation: Facility staff did not allow resident to have a telephone call.
It is alleged that a nurse at the facility took away R1's phone while on a call. Per interviews conducted, (6) of (8) residents denied staff not allowing them to have phone calls and state they have their own cell phones from which they can make their own calls. (5) of (5) staff interviewed stated most residents have their own cell phones, and when a call is received to the facility for them, they are notified of it and are allowed to use the phone upon request/need. This allegation is unsubstantiated.

Regarding allegation: Facility staff threw water in resident's face.
It is alleged that a facility nurse threw water in R1's face for reasons unknown. (7) of (8) residents stated to not have witnessed or have knowledge of a staff throwing water in a residents face. (5) of (5) staff stated they have no knowledge of staff throwing water at R1's face; However (4) of (5) staff have knowledge of an incident where R1 threw food/water in S9's face due to R1 agitated with staff for not serving food quickly enough. This allegation is unsubstantiated.

(Report continued on LIC9099-C...)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

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: 01/13/2023

NARRATIVE

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Regarding allegation: Facility staff do not treat resident with respect.
It is alleged that facility staff make fun of R1. Per interviews conducted, (5) of (8) residents denied the allegation and stated that staff treat them with respect. (5) of (5) staff also denied the allegations and state that they treat residents with respect. This allegation is unsubstantiated.

Regarding allegation: Facility staff handle resident in a rough manner.
It is alleged that facility staff pushed R1 roughly in their wheelchair and bathed them roughly, leaving them with reddish skin color. (6) of (8) residents denied the allegation and stated to not witness staff pushing other residents roughly in their wheelchair and have not experienced rough baths where their skin is left red. (5) of (5) denied the allegation and stated they are gentle with residents and treat them with care. This allegation is unsubstantiated.

Regarding allegation: Facility staff did not return resident's personal property upon termination of serivces.
It is alleged that facility staff did not return R2's personal property upon termination of services. Per interviews conducted, R2 states the facility has yet to return their property. (6) of (8) residents state to not have knowledge of facility staff not returning a resident's belongings upon termination of services. (3) of (5) staff state R2's belongings were returned. S2, and S7-S8 state to have witnessed someone from the new facility where R2 is now residing at, to pick up R2's belongings with R2's permission. LPA reviewed a signed copy of the Move-Out Policy, dated: 9/18/2020 and confirmed that a staff from the new facility did pick-up R2's belongings "as is" per R2's instructions. This allegation is unsubstantiated.

Per California Code of Regulations, Title 22, no deficiencies were observed or cited during today's visit.

An exit interview was conducted with administrator Gil Agas. Due to technical difficulties, a hard copy of this report was provided via email for signature.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2023

LIC9099 (FAS) - (06/04)

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