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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603374
Report Date: 04/03/2025
Date Signed: 04/03/2025 03:31:19 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
06/16/2023 and conducted by Evaluator Erik Zaragoza
COMPLAINT CONTROL NUMBER: 28-AS-20230616151342
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:0CENSUS: 0DATE:
04/03/2025
UNANNOUNCEDTIME BEGAN:
11:51 AM
MET WITH:N/ATIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Resident sustained multiple pressure injuries in care due to staff neglect.
Staff did not properly attend to resident's pressure injuries.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Erik Zaragoza is delivering findings on the complaint allegations listed above. Findings will be mailed to the Licensee as the facility closed effective 8/31/2023.

The investigation consisted of the following: During the initial visit conducted by LPA Jewel Baptiste on 6/20/2023, LPA obtained staff roster, resident roster, and copies of the following documents for resident #1: Admission Agreement, Physician's Report, Needs and Services Plan, Medication Information, Arcadia Living, Levels of Care point based system and Doctors Health Records. On a subsequent visit conducted on 1/11/2024, LPA Baptiste conducted a tour of the facility with the Administrator. LPA obtained the staff roster, resident roster, and R1 relocation information. LPA requested the facility to email R1’s updated physicians report, body checks upon admission, preplacement appraisal, and care plan. LPA interviewed the Administrator and a total of 3 staff, whom shall be referred to as S1 through S3. A total of 7 residents was also interviewed and shall be referred to as R2 through R8. An additional resident and their Responsible party were interviewed and shall be referred to as R9 and W1(witness #1). Today LPA Zaragoza will deliver the findings of the investigation.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025
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 6
Control Number 28-AS-20230616151342
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ARCADIA LIVING LLC
FACILITY NUMBER: 198603374
VISIT DATE: 04/03/2025
NARRATIVE
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In regards to the allegation that "Resident sustained multiple pressure injuries in care due to staff neglect," it is alleged that R1 had developed multiple pressure injuries while they resided at the facility on three (3) separate areas of their body. During interviews with the residents, one (1) out of nine (9) interviewed corroborated the allegation. Most of the residents stated that their needs were being met by the staff and that they were not being neglected. During interviews with the staff, one (1) out of four (4) staff interviewed corroborated the allegation. One of the staff interviewed stated that there were some caregivers in the facility who did not check on R1 at night time as they should have been. Other staff interviewed stated that they did observe R1's pressure injuries and wound dressings to ensure they were kept clean and dry, and if there were any changes they would call the home health agency responsible for changing R1's wounds and providing additional care. Based on the records obtained related to R1's care, it was revealed that R1 had developed multiple pressure injuries on both of their heels and lower back area while they resided at the facility. The pressure injuries were ultimately determined to have been stage 3 pressure injuries. These pressure injuries had resolved following wound care on two (2) separate occasions on 3/23/2023 and 5/3/2023, however they had both reoccurred afterwards when the facility was instructed to regularly observe the pressure injuries and immediately notify R1's physician of any skin changes. This indicates that staff failed to regularly observe the resident's skin for changes including the worsening or development of the pressure injuries while R1 was in the care of the facility.

In regards to the allegation that "Staff did not properly attend to resident's pressure injuries," it is alleged that the facility did not properly reposition R1 in their bed every 2 hours and as needed to relieve pressure and prevent pressure injuries from developing. During interviews with the residents, one (1) out of nine (9) interviewed corroborated the allegation. Most of the residents interviewed indicated that they were satisfied with the care they received from the facility staff. R1 explained that at night they were not repositioned in bed by the staff of the facility. During an interview with W2, they explained that they had hired a private caregiver to assist with rotating R1 at night because they had suspected that staff were not assisting R1 with repositioning in bed as they should have. During interviews with staff, one (1) out of four (4) interviewed corroborated the allegation. One of the staff interviewed stated that they observed that some caregivers in the facility were not repositioning R1 every 2 - 4 hours as they should have been at night. Other staff members interviewed stated that they were assisting with rotating R1 every 2 hours to relieve pressure as required. Based on records reviewed pertaining to R1's pressure injury care, R1 was determined to have required maximum assistance with all Activities of Daily Living (ADLs), including repositioning in bed. [CONT. on LIC9099C].
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 28-AS-20230616151342
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ARCADIA LIVING LLC
FACILITY NUMBER: 198603374
VISIT DATE: 04/03/2025
NARRATIVE
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In April of 2023, R1 was admitted to a Skilled Nursing Facility (SNF) in order to treat their stage 3 and unstageable pressure injuries that had developed while they were living at the facility. R1 was discharged back to the facility on 5/13/2023 after one of their pressure injuries had closed and another one was improving. The SNF had ordered that the facility continue to rotate R1 every 2 - 4 hours or as needed to relieve pressure and prevent the worsening of the pressure injuries. However on 5/15/2023, two (2) days after R1 had returned to the facility, R1's home health agency discovered that the two (2) pressure injuries that were treated by the SNF had reopened and were now stage 3 pressure injuries, and that a new pressure injury had developed as well. This necessitated additional medical interventions including wound care to treat the affected areas. This indicates that there was a lapse in the essential interventions of repositioning R1 every 2 hours and protecting the wound from abrasive forces to prevent the further development of R1's pressure injuries between the dates of 5/13/2023 - 5/15/2023 when she returned from the SNF to the facility.
Immediate Civil Penalties will be issued today, in the amount of $500.00 due to R1 sustaining multiple pressure injuries due to staff neglect, which required mechanical debridement and meets the definition of serious bodily injury. Refer to LIC421IM.

At this time an Enhanced Civil Penalty (ECP) determination is pending in reference to Health and Safety Code 1569.49(f) and may be assessed at a later date.

Based on LPA interviews conducted with the clients and staff, the preponderance of evidence standard has been met for the above allegations, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations Title 22, Division 6, Chapter 8 is being cited on the attached LIC9099D.

A copy of the report along with the appeal rights will be mailed to the licensee's last known mailing address on record.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
06/16/2023 and conducted by Evaluator Erik Zaragoza
COMPLAINT CONTROL NUMBER: 28-AS-20230616151342

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:0CENSUS: 0DATE:
04/03/2025
UNANNOUNCEDTIME BEGAN:
11:51 AM
MET WITH:N/ATIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff did not properly attend to resident's catheter.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Erik Zaragoza is delivering findings on the complaint allegations listed above. Findings will be mailed to the Licensee as the facility closed effective 8/31/2023.

The investigation consisted of the following: During the initial visit conducted by LPA Jewel Baptiste on 6/20/2023, LPA obtained staff roster, resident roster, and copies of the following documents for resident #1: Admission Agreement, Physician's Report, Needs and Services Plan, Medication Information, Arcadia Living, Levels of Care point based system and Doctors Health Records. On a subsequent visit conducted on 1/11/2024, LPA Baptiste conducted a tour of the facility with the Administrator. LPA obtained the staff roster, resident roster, and R1 relocation information. LPA requested the facility to email R1’s updated physicians report, body checks upon admission, preplacement appraisal, and care plan. LPA interviewed the Administrator and a total of 3 staff, whom shall be referred to as S1 through S3. A total of 7 residents was also interviewed and shall be referred to as R2 through R8. An additional resident and their Responsible party were interviewed and shall be referred to as R9 and W1(witness #1). Today LPA Zaragoza will deliver the findings of the investigation.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 28-AS-20230616151342
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ARCADIA LIVING LLC
FACILITY NUMBER: 198603374
VISIT DATE: 04/03/2025
NARRATIVE
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In regards to the allegation that "Staff did not properly attend to resident's catheter," it is alleged that R1 did not receive proper catheter care in not obtaining assistance in emptying their catheter at night, which ultimately led to their hospitalization on 5/27/2023 for a distended bladder. During interviews with the residents, eight (8) out of nine (9) interviewed did not corroborate the allegation. Most residents interviewed stated that all of their needs are being adequately met by the facility staff. During interviews with the staff, three (3) out of four (4) interviewed did not corroborate the allegation. One staff member stated that they did assist with emptying R1's catheter every 2 - 4 hours and as needed, and that they worked with a home health agency who assisted R1 with self-catheterization and providing R1 with their catheter supplies. Another staff interviewed likewise stated that staff were responsible for emptying R1's catheter whenever it was becoming full or every 2 - 4 hours. Based on records reviewed related to R1's catheter care, it was determined that following R1's hospitalization their symptoms were immediately alleviated and no further medical interventions were needed. LPA was not able to obtain any additional information on the events leading up to R1's hospitalization on 5/27/2023.

Based on statements and interviews conducted with staff, clients, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

A copy of the report along with the appeal rights will be mailed to the licensees last known mailing address on record.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 28-AS-20230616151342
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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: 04/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/13/2025
Section Cited
CCR
87468.2(a)(8)
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(a) In addition (...) residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (8) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse.
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Licensee/Administrator is to ensure that regular body checks are conducted on residents that are at risk of developing pressure injuries at all times. Licensee/Adminisrator is to submit a written plan to the LPA explaining how they will ensure that they will regularly observe the skin of (...)
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This regulation is not met as evidenced by:
Based on record review and interviews, the facility neglected R1 by failing to regularly observe the condition of R1's skin which led to them developing pressure injuries, which posed an immediate health and safety risk to clients in care.
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residents who are identified as being at risk of developing or reopening pressure injuries by the POC due date.
Type A
03/13/2025
Section Cited
CCR
87465(a)(1)
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(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical (...) care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange (...) for medical or dental care appropriate to the conditions and needs of residents.
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Licensee/Administrator is to ensure that a medical plan is developed for all residents and followed by the staff at all times. Licensee/Administrator is to submit a written plan to the LPA explaining how they will ensure that they will adhere to the medical plans for all residents by the POC due date.
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This regulation is not met as evidenced by:
Based on record review and interview, the facility did not follow the medical plan for R1 by failing to rotate R1 properly every 2 hours and led to the reoccurence of their pressure injuries, which posed and immediate health and safety concern to residents 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.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6