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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603401
Report Date: 01/13/2025
Date Signed: 01/13/2025 12:07:35 PM

Document Has Been Signed on 01/13/2025 12:07 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: 75DATE:
01/13/2025
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Gil Agas, administrator
Justin Lee, administrator assistant		TIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Tao and DeLeon conducted an unannounced Case Management- Health and safety check visit at the facility. LPA met with Gil administrator and Justin Lee administrator assistant. The purpose of today's visit was explained to them.

On today’s visit, LPAs conducted a physical plant and interviewed with staff. LPAs obtained copies of the following documents:
· Staff roster
· Resident roster

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

LPAs requested to make copies of the residents' files. Gil, administrator, allowed LPAs to access residents' files. However, Justin Lee refused to allow LPAs to make photocopies of the residents' files during the visit. Justin only allowed LPAs to review the files and insisted not allow LPAs to make copies of any residents' files. Justin requested for two (2) days delay for LPAs to make copies of the files.

Licensee was not in compliance with Title 22 and may be fined with a civil penalty. Deficiencies were observed and cited during this visit. Exit interview was held with Justin. This report LIC 809 and LIC 809D were provided.

Justin declined to sign LIC 809s reports and indicated these reports would not be signed.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 01/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/13/2025
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 01/13/2025 12:07 PM - It Cannot Be Edited


Created By: Bonnie Tao On 01/13/2025 at 11:29 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: 01/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/14/2025
Section Cited
CCR
87506(d)

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(d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying.

This requirement is not met as evidenced by:
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Licensee shall have residents files available to licensing to copy upon visit with in 24 hours. POC due date 01/14/25
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Based on observation, the licensee did not allow LPAs to make photocopies of residents' files upon demand during normal business hours visit . This poses a potential health and safety risk to residents
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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: 01/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2025


LIC809 (FAS) - (06/04)
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