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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603401
Report Date: 01/28/2025
Date Signed: 01/28/2025 03:25:42 PM

Document Has Been Signed on 01/28/2025 03:25 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:
01/28/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:30 PM
MET WITH:Virgilio Agas, administrator, and
Justin Lee, administrator assistant		TIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Tao and DeLeon conducted an unannounced case management visit during the complaint visit on 12/24/24. LPA met with administrator, Gil and administrator assistant, Justin Lee. The purpose of the visit was to conduct a Health and Safety check and issue citations. The purpose was discussed with Gil. LPAs conducted a physical plant of the facility and reviewed residents/staff files. LPAs obtained a copy of the staff/ client roster.

On 12/24/24, LPA Tao interviewed resident#1(R1). The interview revealed hot water was delivered to resident’s bathroom and the water temperature was above 120 degree F. LPA toured the facility and tested the water temperature in other residents’ rooms. The water temperature was measured in a range from 123.8 degree F to 125 degree F. Thus, the hot water that delivered to residents for showers was too hot and not in compliance with Title 22 regulations.

During the physical plant on 12/24/25, LPA Tao observed the resident#1 (R1)’s room had stained spots on the carpet and the resident’s bathroom had missing vinyl pieces on the floor at the entrance area. Thus, the resident’s room was in disrepair.

Deficiencies of Health and Safety were observed per Title 22 Regulations Division 6 Chapter 8. Exit interview was conducted with administrator and a copy of this report, LIC 809D, and appeal rights were provided.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/28/2025
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 01/28/2025 03:25 PM - It Cannot Be Edited


Created By: Bonnie Tao On 01/28/2025 at 12:00 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: 01/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/29/2025
Section Cited
CCR
87303(e)(2)

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(2) … hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C)

This requirement was not met by evidence of:
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Licensee agreed to adjust the hot water temperature in a range of 105 -120 degree F. POC was cleared on the day of visit.
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Based on interviews and observation, the hot water delivered to residents’ rooms was above 120 degree F. Licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
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Type B
01/29/2025
Section Cited
CCR87303(a)

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The facility shall be clean, safe, sanitary and in good repair at all times.

The requirement is not met by evidence of:
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Licensee agreed to repair the bathroom floor and clean the carpet by POC due date. POC was cleared on the day of visit.
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R1’s room had stain spots on the carpet and broken vinyl flooring in the bathroom. 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: 01/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2025


LIC809 (FAS) - (06/04)
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