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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603374
Report Date: 10/18/2022
Date Signed: 10/18/2022 06:28:18 PM

Substantiated


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
10/10/2022 and conducted by Evaluator Bonnie Tao
COMPLAINT CONTROL NUMBER: 28-AS-20221010164036
FACILITY NAME:ARCADIA LIVING LLCFACILITY NUMBER:
198603374
ADMINISTRATOR:JINGFANG JENNIFER ZHANGFACILITY TYPE:
740
ADDRESS:601 SUNSET BOULEVARDTELEPHONE:
(626) 447-0106
CITY:ARCADIASTATE: CAZIP CODE:
91007
CAPACITY:130CENSUS: 48DATE:
10/18/2022
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Jennifer Zhang, AdministratorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Facility neglected resident's call requests after sustaining a fall.
Facility staff failed to seek medical evalution to resident after sustaining a fall.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tao conducted unannounced complaint investigation for the allegations listed above. During today’s visit, LPA met administrator, Jennifer Zhang. LPA explained the purpose of today's visit regarding the above-mentioned allegations.

Investigation consisted of the following: interviews of staff from Staff #1 (S1) through Staff #6 (S6) and attempted to interview Staff#7; interviews of residents from resident#2 (R2) through resident #5 (R5) and attempted to interview resident#1and visitor #1 (V1); reviews of resident#1’s record; and a facility tour. LPA obtained copies of the staff and resident rosters, and resident #1s’ records with relevant information.

The investigation revealed the following:

(-continued in LIC 9099 C-)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2022
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-20221010164036
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 LIVING LLC
FACILITY NUMBER: 198603374
VISIT DATE: 10/18/2022
NARRATIVE
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Regarding the allegation “facility neglected resident's call requests after sustaining a fall," it was alleged that staff did not respond to multiple call button requests for assistance from resident after sustaining a fall. LPA attempted to interview resident#1 but unable to interview since resident discharged on 10/17/22 and responsible party did not answer LPA's multiple calls. Four (4) out of five (5) residents stated it took staff about 30 minutes or more to respond their call button requests and come to residents' room to assist residents. One (1) out of five (5) residents stated it took about 3 minutes for staff to come to assist. Interviewed staff from staff#1 to staff #6 and they denied the allegation. Six (6) out of six (6) staff denied the allegation. Three (3) staff stated staff did not respond to resident#1's call button request on 10/1/22 because R1 did not press the call button for help. The call button was pressed by staff who found R1 after sustaining a fall. LPA toured the facility with administrator and went to room #110 and #112 to test the call button requests, staff responded and came to the residents’ room in 5 minutes. However, resident interviews revealed facility did not respond resident's call requests on a timely basis to assist residents.

Regarding the allegation “facility staff failed to seek medical evaluation to resident after sustaining a fall," it was alleged that facility staff did not seek a medical evaluation for resident#1 after sustaining a fall. Five (5) out of five (5) residents could not corroborate the allegation.

Five (5) out of six (6) staff stated they did not seek a medical evaluation for resident#1 after sustaining a fall. File reviews revealed facility did not seek medical evaluation after the incident on 10/1/22. Therefore, staff failed to seek medical evaluation to resident after sustaining a fall.

Based on review of documents and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22, Division 6, Chapter 8.

An exit interview was conducted with Administrator. A hard copy of this report and appeal rights were provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20221010164036
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 LIVING LLC
FACILITY NUMBER: 198603374
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/19/2022
Section Cited
CCR
87415(a)(3)
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In facilities caring...and one employee shall be on call and capable of responding within ten minutes.
This requirement is not met as evidence by:
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Facility will provide in service training regarding responding timely to call button request/ call system to resident. Provide proof of correction to Licensing by 10/19/22.
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Staff responded to residents' call button in more than 30 minutes which poses an immediate Health, Safety, Personal rights risk to persons in care.
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Type B
10/26/2022
Section Cited
CCR
87468.1(a)(16)
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(a) Residents in all residential care facilities for the elderly shall have all of the following personal right: (16)To receive... medical care
This requirement is not met as evidence by:
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Facility will provide in service training educating staff regarding the providing of medical assistance and evaluation to residents by 10/26/22.
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Facility failed to provide Resident#1 a medical evalutation on a timely basis after sustaining a fall which poses a potential Health, Safety, Personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3