198602098-4-6-2021-28-AS-RORN-C22245-20210412170321

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602098
Report Date: 04/01/2021
Date Signed: 04/06/2021 02:08:45 PM

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
05/06/2020 and conducted by Evaluator David Sicairos

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20200506082127

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: 63	DATE:	04/01/2021
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Virgilio Agas; Administrator		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff provided wrong medication to resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) David Sicairos 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 Virgilio Agas.

The investigation consisted of the following: during initial televisit conducted on 05/12/20, LPA Irra conducted a telephone interview with the Administrator and Resident #1 (R1). LPA requested copies of: Staff and Resident Roster. For R1: Emergency Contact information, Admission Agreement, Appraisal Needs and Services Plan, Current Physician’s Report, Physician’s Orders for PRNs, Medication Administration Record (MAR) for April 2020 and May 2020 including administration of PRNs and notes pertaining to medication for R1. For Staff records for Staff #1 (S-2), Mandated Report Training, Resident Rights training and Medication Administration Training (including administration of PRNs). On 09/25/20, LPA Sicairos conducted phone interviews with S2 and Resident #2 (R2) - Resident #9 (R9). Staff #1 (S1) was interviewed over the phone by LPA Flores.

(CONTINUED ON 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David Sicairos	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR SIGNATURE:	DATE: 04/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2021

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-20200506082127

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: 04/01/2021

NARRATIVE

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The investigation revealed the following: in regards to the allegation "staff provided wrong medication to resident", it is alleged that S2 provided R1 with the wrong medication (Lorazepam). Per review of Medication Records, R1 was prescribed Lorazepam until it was discontinued on 05/31/20 by their Physician. Facility staff dispensed medication as directed. Staff members interviewed indicated that medications are provided to all residents as instructed by the Physicians Orders. Staff members interviewed denied having provided R1 or any other resident with the wrong medication. Interviews conducted with R2 - R9 all indicated that they receive their prescribed medication in a timely manner. Therefore there was insufficient evidence to corroborate with this allegation.

Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegation. 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.

Telephonic exit interview held, and a copy of this report was emailed to Administrator for signature.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David Sicairos	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR SIGNATURE:	DATE: 04/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2021

LIC9099 (FAS) - (06/04)

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