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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603401
Report Date: 08/30/2025
Date Signed: 08/30/2025 11:43:44 AM

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
08/30/2024 and conducted by Evaluator Alberto Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240830151706
FACILITY NAME:ARCADIA RETIREMENT VILLAGEFACILITY NUMBER:
198603401
ADMINISTRATOR:VIRGILIO AGASFACILITY TYPE:
740
ADDRESS:607 WEST DUARTE RDTELEPHONE:
(626) 447-6070
CITY:ARCADIASTATE: CAZIP CODE:
91007
CAPACITY:200CENSUS: DATE:
08/30/2025
UNANNOUNCEDTIME BEGAN:
11:01 AM
MET WITH:Jennifer Arroyo, Med. Tech TIME COMPLETED:
11:44 AM
ALLEGATION(S):
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Staff did not follow proper reporting requirements
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced subsequent complaint visit and met with Jennifer Arroyo, Med. Tech and discussed purpose for today's visit.
On 9/17/2024 Licensing Program Analyst (LPA) Jewel Baptiste conducted an announced subsequent complaint visit and met with Manager Justin Le and discussed purpose for today's visit.
During the initial visit, LPA obtained the following documents: Staff roster, resident roster, and the facility menu. During the visit LPA did not observe any health and safety concerns.
During today's visit, LPA obtained the following documents: Staff roster, resident roster, house rules, R5 admissions agreement, police report, and an invoice from F&W Food Service. During the visit LPA toured the facility with the Manager Justin Le. LPA Baptiste interviewed a total of 4 staff who shall be referred to as S1 through S4. LPA interviewed a total of 7 residents who shall be referred to as R2 through R8.
On 09/05/2024, Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced visit to the facility regarding the allegations listed above. Upon arrival LPA was greeted by the Administrator Agas Virgilio and explained the reason for the visit.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2025
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-20240830151706
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 RETIREMENT VILLAGE
FACILITY NUMBER: 198603401
VISIT DATE: 08/30/2025
NARRATIVE
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(continued from 9099)

During today's visit, LPA obtained the following documents: Staff roster, resident roster, and the facility menu. During the visit LPA did not observe any health and safety concerns.
The investigation consisted of LPA interviewing five (5) staff members and eight (8) residents. R9 passed before LPA could not interview R9, review and obtain staff and resident rosters.
The interviews conducted by LPA Baptiste and were not considered in determining the findings since LPA Lopez did not have access to the interviews and conducted new interviews.


Allegation: Staff did not follow proper reporting requirements. It is alleged that the facility failed to report to ombudsman as required by law. LPA interviewed five (5) staff, and all five (5) staff members denied the allegations. All staff stated that they comply with reporting requirements. LPA interviewed eight (8) residents, and all eight (8) residents could not corroborate the allegations. All eight residents stated that they did not know about this. LPA reviewed facility incident reports, and it appears that the facility failed to report the incident during which R9 was tossing items at staff. There is sufficient evidence to support this allegation.

Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. A deficiency is being cited. See LIC 9099D.


Exit interview was conducted with Jennifer Arroyo, Med. Tech . A copy of the report and appeal rights was provided.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2025
LIC9099 (FAS) - (06/04)
Page: 6 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
08/30/2024 and conducted by Evaluator Alberto Lopez
COMPLAINT CONTROL NUMBER: 28-AS-20240830151706

FACILITY NAME:ARCADIA RETIREMENT VILLAGEFACILITY NUMBER:
198603401
ADMINISTRATOR:VIRGILIO AGASFACILITY TYPE:
740
ADDRESS:607 WEST DUARTE RDTELEPHONE:
(626) 447-6070
CITY:ARCADIASTATE: CAZIP CODE:
91007
CAPACITY:200CENSUS: DATE:
08/30/2025
UNANNOUNCEDTIME BEGAN:
11:01 AM
MET WITH:Jennifer Arroyo, Med. Tech TIME COMPLETED:
11:44 AM
ALLEGATION(S):
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Staff hit resident in care
Staff caused injury to resident in care
Staff did not ensure a safe environment was provided to residents in care
Staff did not safeguard resident's personal belongings
Staff spoke inappropriately to residents in care
Staff did not provide proper food service to resident in care
Staff did not provide mobility assistance to resident in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced subsequent complaint visit and met with Jennifer Arroyo, Med. Tech and discussed purpose for today's visit.
On 9/17/2024 Licensing Program Analyst (LPA) Jewel Baptiste conducted an announced subsequent complaint visit and met with Manager Justin Le and discussed purpose for today's visit.
During the initial visit, LPA obtained the following documents: Staff roster, resident roster, and the facility menu. During the visit LPA did not observe any health and safety concerns.
During today's visit, LPA obtained the following documents: Staff roster, resident roster, house rules, R5 admissions agreement, police report, and an invoice from F&W Food Service. During the visit LPA toured the facility with the Manager Justin Le. LPA Baptiste interviewed a total of 4 staff who shall be referred to as S1 through S4. LPA interviewed a total of 7 residents who shall be referred to as R2 through R8.
On 09/05/2024, Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced visit to the facility regarding the allegations listed above. Upon arrival LPA was greeted by the Administrator Agas Virgilio and explained the reason for the visit. (continued on 9099C)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 28-AS-20240830151706
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 RETIREMENT VILLAGE
FACILITY NUMBER: 198603401
VISIT DATE: 08/30/2025
NARRATIVE
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(continued from 9099A)

During today's visit, LPA obtained the following documents: Staff roster, resident roster, and the facility menu. During the visit LPA did not observe any health and safety concerns.

The investigation consisted of LPA interviewing five (5) staff members and eight (8) residents. R9 passed before LPA could not interview R9, review and obtain staff and resident rosters.

The interviews conducted by LPA Baptiste and were not considered in determining the findings since LPA Lopez did not have access to the interviews and conducted new interviews.

The investigation revealed regarding allegation: Staff hit resident in care. It is alleged that staff hit R9 and bruised the resident. LPA interviewed five (5) staff, and all five (5) staff denied the allegation. Eight (8) of seven (7) residents could not corroborate the allegation. One (1) staff stated that R9 was throwing items at staff and that staff threw them back, but staff stated that R9 was never hit. S#3 denied the allegation. R9 has since passed, and LPA was not able to interview R9. There was no time or date provided as to when the allegation occurred. There is insufficient evidence to support this allegation.

Allegation: Staff caused injury to residents in care. It is alleged that staff caused a bruise to resident arm by grabbing it. LPA interviewed five (5) staff members, and all five (5) staff members denied the allegation. LPA interviewed eight (8) residents, and all eight (8) residents could not corroborate the allegation. S3 stated that R9 threatened S3 and attempted to run S3 over with wheelchair. S3 stated that R9 was drunk and S3 took away the alcohol from R9 and R9 proceeded to slap S3. S3 stated that S3 held R9 hand to defend S3. S1 stated that bruise may be from R9 medication. There was no witness to the incident. There is insufficient evidence to support this allegation.

Allegation: Staff did not ensure a safe environment was provided to residents in care. It is alleged that facility staff do not provide a safe environment for residents. LPA interviewed five (5) staff, and all five (5) staff denied the allegation. LPA interviewed eight (8) residents, and all eight (8) residents could not corroborate the allegation, and all eight (8) residents stated they felt safe at the facility. There is insufficient evidence to support this allegation.

Allegation: Staff did not safeguard resident's personal belongings. It is alleged that several residents have had items missing from their room and blamed staff. LPA interviewed five (5) staff members, and all five (5) staff members denied the allegations. Several staff members stated that residents will always blame staff if they are missing their items. Staff members denied taking anything from the resident’s room. LPA interviewed eight (8) residents and six (6) of eight (8) denied the allegation. One (1) resident discovered their missing item was taken by another resident and got it back. Some residents stated that residents have a bad habit of leaving their doors unlocked and other residents can easily walk in to remove items that do not belong to them. There is insufficient evidence to support this allegation.

(continued on 9099C)

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 28-AS-20240830151706
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 RETIREMENT VILLAGE
FACILITY NUMBER: 198603401
VISIT DATE: 08/30/2025
NARRATIVE
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(continued from 9099C)

Allegation: Staff spoke inappropriately to residents in care. It is alleged that staff are verbally abusive to residents. LPA interviewed five (5) staff, and all five (5) staff denied the allegation. Some staff stated it is the other way around. LPA interviewed eight (8) residents and seven (7) of eight (8) staff could not corroborate the allegation. Seven (7) of eight (8) residents stated that the staff is respectful and nice to them. There is insufficient evidence to support this allegation.

Allegation: Staff did not provide proper food service to resident in care. It is alleged that the facility left resident, while bedridden, without food or water for four (4) days. LPA interviewed five (5) staff, and all five (5) staff denied the allegation. One (1) staff member stated that it is ridiculous and that other agencies that come to facility would have become aware of this if it were true. One staff member stated that R9 ordered food, and it was left at his door. LPA interviewed eight (8) residents, and all eight (8) residents stated that they get their meals on time everyday and have no issue with the food service at the facility. There is insufficient evidence to support this allegation.

Allegation: Staff did not provide mobility assistance to resident in care. It is alleged that the facility staff did not provide mobility assistance to resident. LPA interviewed five (5) staff, and all five (5) staff denied the allegation. One staff member stated that R9 has own mobility. Another staff member stated R9 has an electric wheelchair and can move on R9 own. LPA interviewed eight (8) residents, and all eight (8) residents could not corroborate the allegation. One resident stated that they get assistance all the time if needed. Another resident stated that the facility provides them with mobility assistance if required. There is insufficient evidence to support this allegation.

Based on statements and interviews conducted with staff and residents, 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.

An exit interview was held with the Administrator, Jennifer Arroyo, Med. Tech , and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 28-AS-20240830151706
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 RETIREMENT VILLAGE
FACILITY NUMBER: 198603401
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/05/2025
Section Cited
CCR
87211(a)(1)
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87211(a)(1). Reporting Requirements: Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name.
This requirement is not met as evidenced by:
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Administrator will send incident report(s) to CCLD and Ombudsman regarding the incident and any other incidents that involved R9 by POC date.
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An an incident occurred at the facility where R9 was tossing items at staff and the facility failed to report to licensing which poses/posed a potential health and safety 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.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6