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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603401
Report Date: 12/20/2024
Date Signed: 12/20/2024 05:59:39 PM

Document Has Been Signed on 12/20/2024 05:59 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: 77DATE:
12/20/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Virgilio Agas, administrator
Justin Lee, administrator assistant
Fernando Fierros, Licensing Program Manager
Bonnie Tao, Licensing Program Analyst		TIME VISIT/
INSPECTION COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tao and Licensing Program Manager (LPM) Fierros conducted an unannounced Case Management- Health and safety check visit at the facility. The facility was licensed to serve the elderly who are 60 years and older and had 25 hospice wavier approved. Its capacity was 200 residents including 149 non-ambulatory, of which 15 may be bedridden. LPA and LPM met with Gil Agas, administrator and Justin Lee, administrator assistant. The purpose of today's visit was explained to them.

On today’s visit, LPA and LPM conducted a physical plant, reviewed/obtained 15 residents’ files. Licensing conducted the physical plant with Gil and Justin and toured all three floors at the premises. During the physical plant, all 50 carbon monoxide devices at the facility were not working.

LPA obtained copies of the following documents:
· Staff roster
· Resident roster
· 15 residents files

LPA and LPM did not observe nor identify signs of neglect, abuse or other immediate health and safety threats.

Deficiencies were observed and cited in LIC 809 D during this visit. Exit interview was held with administrator. This report LIC 809 and appeal rights were provided to administrator.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2024
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 12/20/2024 05:59 PM - It Cannot Be Edited


Created By: Bonnie Tao On 12/20/2024 at 05:31 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: 12/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/20/2024
Section Cited
HSC
1569.311

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Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards…

The requirement is not met by evidence of:
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Licensee agreed repair/ replace the 50 carbon monoxide devices. Licensee had fixed the 50 devices today 12/20/24. POC is cleared during the visit.
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All 50 carbon monoxide detectors were not operable during the visit.
Based on interviews and 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 Fierros
LICENSING EVALUATOR NAME:Bonnie Tao
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2024


LIC809 (FAS) - (06/04)
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