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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603401
Report Date: 02/25/2022
Date Signed: 02/28/2022 10:14:34 AM

Document Has Been Signed on 02/28/2022 10:14 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 VILLAGEFACILITY NUMBER:
198603401
ADMINISTRATOR:VIRGILIO, AGASFACILITY TYPE:
740
ADDRESS:607 WEST DUARTE RDTELEPHONE:
(626) 447-6070
CITY:ARCADIASTATE: CAZIP CODE:
91007
CAPACITY: 200CENSUS: 67DATE:
02/25/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Administrator / Virgilio "Gil" AgasTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced case management visit to this facility. During a complaint investigation conducted at this facility, LPA reviewed the physician's report for Resident #1 (R1) and discovered that R1 has a diagnosis of dementia. The physician's report is dated: 2/3/22, and was completed/signed by Dr. Nolan Cordell.
Arcadia Retirement Village does not have an approved Dementia Care Plan in their plan of operation and is not allowed to accept or care for residents with dementia. This poses an immediate health and safety risk to R1.


The following deficiency was observed to be in violation of California code of Regulations, Title 22, Division 6 (refer to 809D)
An exit interview was conducted and a copy of this report was provided to the Administrator along with the Appeals Rights.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE: DATE: 02/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/25/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/28/2022 10:14 AM - It Cannot Be Edited


Created By: Joe Katrdzhyan On 02/28/2022 at 09:18 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 02/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/26/2022
Section Cited
CCR
87705(b)

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Care of Persons with Dementia. In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including: refer to Section 87705(b)(1-2).
This requirement is not being met as evidenced by: During a complaint investigation
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Administrator will submit a plan to CCL ensuring the safety measures the facility will implement to ensure that the health and safety of R1 are being met. Plan must also state if Licensee will be submitting an updated program plan to incorporate Dementia Care Plan as part of its operation or a time frame when R1 will be relocated to a facility which offers Dementia
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conducted at this facility, LPA reviewed the physician's report for Resident #1 (R1) and discovered that R1 has a diagnosis of dementia. The physician's report is dated: 2/3/22, and was completed/signed by Dr. Nolan Cordell. Arcadia Retirement Village does not have an approved Dementia Care Plan in their plan of operation and is not allowed to accept or care for residents with dementia. This poses an immediate health and safety risk to R1.
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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:Wei Siew Ho
LICENSING EVALUATOR NAME:Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE:
DATE: 02/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2022


LIC809 (FAS) - (06/04)
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