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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603401
Report Date: 05/05/2022
Date Signed: 05/05/2022 07:53:25 PM


Document Has Been Signed on 05/05/2022 07:53 PM - 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: 78DATE:
05/05/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Virgilio Agas, Administrator
Justin Lee, Assistant Administrator		TIME COMPLETED:
05:00 PM
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Licensing Program Analysts (LPAs) Tao and Calderon conducted an unannounced case management visit. LPAs met with Administrator, Virgilio Agas, and Assistant Administrator, Justin Lee, who both assisted with the visit. The purpose of the visit was to check on the Health and Safety of the Residents and facility. The purpose was discussed with Virgilio and Justin.

On today’s visit LPAs conducted a health and safety check. LPAs toured the physical plant of the facility and staff file reviews. LPAs obtained a copy of the Staff roster, Resident roster, Pest control service report, electrician report of the generator, and emergency plan during the visit.

During the visit, LPAs observed the following:

1) Front entrance door – door latch is broken and not securely installed on the door.

2) Exterior wall of the facility – spider webs and dirt buildup are observed.

3) Med Room – a medication cabinet is broken and cabinet is unable securely set in place.

4) TV room (Room #102)- Screen doors are ripped and has holes. Flooring has loose pieces at the entrance which can be slide back and forth.

5) Hallway flooring is peeling near resident room #112, dining room, and emergency food storage.

6) Resident room’s window screens have holes or ripped in resident room #104, #113, #211, #235, #236, #246, #238, #300, #331, #333, and #334.

7) Resident room #119 (room in use) – Resident room’s screen door’s screens have holes and ripped.

8) Resident room #115 (room in use) – The light bulb at the back courtyard is missing. ( -continued in LIC 809C-)

SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 198603401
VISIT DATE: 05/05/2022
NARRATIVE
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9) Resident room #116 (vacant room) – a hole above the bathroom shower facet is observed.

10) Resident room #116 (vacant room) – three (3) dead cockroaches are observed in the bathroom drawer and under the sink.

11) Back courtyard – three (3) small empty plastic wine bottles are observed on the ground

12) Back courtyard – trash and broken furniture are observed.

13) Front courtyard – four (4) lights on the hallway are not working

14) Resident room #225’s balcony- bottom corner on the left side of the projected section is chipped.

15) Dried beehives are observed on the balcony roofs and removed during the visit in Resident room #203, #301 and #331. No live bees are observed.

16) Rotten wood is observed on resident room’s eaves in resident room #205 and #300.

17) Resident room # 111- Entrance ceiling is ripped and has holes.

18) Glass on the fire extinguisher holder’s doors are missing near resident room #115, resident room #308 and by the kitchen.

19) Resident Laundry room on 1st floor – metal entrance floor cover at the door is loose and not securely install in place.

20) Dead cockroaches are observed in Emergency food storage,

21) Emergency food storage – expired emergency water supply is observed. Expiration date: 2/14/19.

22) Restroom – public restroom next to dining room is not operable. Sink has no water, toilet does not work and wall paper at the back wall is peeled.

23) Private dining room – rodent droppings are observed. Referred to complaint 28-AS-20220429164803 for information and citation.

24) Kitchen – the light in the kitchen food supply room is not working and ceiling cover is ripped.

(- continued in LIC 809C-)

SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2022
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 198603401
VISIT DATE: 05/05/2022
NARRATIVE
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25) Kitchen – right side of entrance door’s hinge cartridge assembly/ door closer is broken. A hole on the ceiling cover near the entrance is observed.

26) Kitchen – the cover of an unknown device on top of the first aid box is missing.

27) Kitchen – the door of the janitor room in the kitchen cannot be closed and the hinge is loose.

28) First aid – First aid box items are either missing or expired. American red cross manual is missing.

29) Storage room #234 and # 310 - lock is broken.

30) Resident room #233 (room in use) – Flooring has loose pieces at the entrance and blind is broken.

31) Resident room #227 (room in use) – Window glass is missing and covered with a cardboard.

32) Resident room #206 (vacant) – Heater is not working. Bathroom’s mirror is cracked. Water facet is missing.

33) Resident room #204 (vacant) – air condition (A/C) is not working. Mold is observed on the ceiling at the entrance. Ceiling cover inside resident’s closet is missing.

34) A/C is not working in resident room #205 (vacant), #316 (vacant), and #317 (vacant).

35) Resident room #309 (vacant) – A/C is not working. Cover plates of two (2) electric outlets are missing.

36) Resident room #320 (room in use) – A/C is not working. Ceiling at the entrance has holes. Flooring has loose pieces near the bathroom.

37) Janitorial room – two (2) live cockroaches are observed behind the door.

38) Roof is leaking – rooftop of resident room #204 (room in use) where outside of resident room #309 (vacant) has a blue plastic sheet covering it due to leaking when raining.

39) Roof is leaking – resident room #304’s (room in use) roof is leaking.

40) Window blinds are broken in resident room #103 (room in use), #106 (room in use), #107 (room in use), #109 (room in use), #110 (room in use), #111 (room in use), #112 (room in use), #115 (room in use), #116 (vacant), #117 (room in use), and #119 (room in use).

(- continued in LIC 809C-)

SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2022
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 198603401
VISIT DATE: 05/05/2022
NARRATIVE
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41) CPR training, First aid training, and in-service annual training are missing from staff file from Staff #1- Staff #6

42) Emergency generator requires maintenance. Administrator and assistant administrator stated the emergency generator is operable but need maintenance to get certified by fire inspector.


Deficiencies of Health and Safety were observed per Title 22 Regulations Division 6 Chapter 8.

Exit interview was conducted with assistant administrator, Justin Lee, and a copy of this report, LIC 809D, LIC 421M- civil penalty 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: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2022
LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 05/05/2022 07:53 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 198603401

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/13/2022
Section Cited

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Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement was not met as evidenced by:
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Emergency generator is operable but requires maintenance before getting fire department's certification. (item#42 on LIC 809).

Based on observation, the Administrator did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
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Type B
05/16/2022
Section Cited

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Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement was not met as evidenced by:
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Facility observed to be not in good repair in residents' rooms, common areas and Med room. They are listed on LIC 809s from items #1- items #40.
Based on observation, the Administrator did not comply with the section cited above which poses a potential health, safety or 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: 05/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2022
LIC809 (FAS) - (06/04)
Page: 5 of 6


Document Has Been Signed on 05/05/2022 07:53 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 198603401

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/16/2022
Section Cited

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All RCFE staff ... shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69.(1) ...receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.
This requirement is not being met as evidenced by:
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CPR training, First aid training, and in-service annual training are missing from staff file from Staff #1- Staff #6 (item#41 on LIC 809)

Based on observation, the Administrator did not comply with the section cited above which poses a potential health, safety or 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: 05/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2022
LIC809 (FAS) - (06/04)
Page: 6 of 6