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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603401
Report Date: 10/22/2024
Date Signed: 10/22/2024 04:09:59 PM

Document Has Been Signed on 10/22/2024 04:09 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/
DIRECTOR:		VIRGILIO AGASFACILITY TYPE:
740
ADDRESS:607 WEST DUARTE RDTELEPHONE:
(626) 447-6070
CITY:ARCADIASTATE: CAZIP CODE:
91007
CAPACITY: 200CENSUS: 83DATE:
10/22/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:31 PM
MET WITH:Virgilio AgasTIME VISIT/
INSPECTION COMPLETED:
04:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza generated this Case Management - Deficiencies report in conjunction with complaint control # 28-AS-20241017120729 pertaining to observations made during the physical plant inspection of resident rooms.The purpose of the report was explained to Administrator Virgilio Agas and Manager Justin Lee.

Observations:
  • Room # 117 call signal wall mount did not have a cover and wiring was exposed. There are 2 bedridden residents residing in the room without access to the facility call signal system. Both stated they use their personal cell phones to call for assistance, and/or yell for help.

  • The electrical wall outlet below the call signal wall mount did not have a cover.

Per Title 22, 87303(i)(1). Maintenance and Operation. Facilities licensed for 16 or more and/or facilities that have separate floors or buildings shall have a signal system which meets specified requirements. Operate from each resident's living unit. A citation was issued.

An exit interview was conducted and a copy of the report and appeal rights were issued to Administrator Virgilio Agas.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2024
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 10/22/2024 04:09 PM - It Cannot Be Edited


Created By: Noemi Galarza On 10/22/2024 at 03:31 PM
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: 10/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/23/2024
Section Cited
CCR
87303(i)(1)

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Maintenance and Operation. Facilities licensed for 16 or more and/or facilities that have separate floors or buildings shall have a signal system which meets specified requirements. Operate from each resident's living unit. This requirement was not met by evidence of:
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Administration staff agreed to repair the signal system box wiring and electrical issues in room 117. Administrator agreed to submit a written plan of correction by tomorrow, and proof of correction i.e. work order invoice, and pictures of the room signal system wall mount. If an extension to the POC is needed, a written request must be submitted to LPA before due date.
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Based on physical plant observation, 2 bedridden residents in room #117 have a call signal wall mount that did not have a cover and wiring was exposed, as well as a wall outlet was observed to be missing a cover, which poses an immediate health and safety risk.
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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:Lisa Hicks
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 10/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2024


LIC809 (FAS) - (06/04)
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