198603401-7-8-2021-28-AS-FFIS-CE5QK4-20220505121341

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603401
Report Date: 07/08/2021
Date Signed: 07/08/2021 02:17:04 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/29/2021 and conducted by Evaluator Bonnie Tao

COMPLAINT CONTROL NUMBER: 28-AS-20210629124250

FACILITY NAME:	ARCADIA RETIREMENT VILLAGE		FACILITY NUMBER:	198603401
ADMINISTRATOR:	VIRGILIO, AGAS		FACILITY TYPE:	740
ADDRESS:	607 WEST DUARTE RD		TELEPHONE:	(626) 447-6070
CITY:	ARCADIA	STATE: CA	ZIP CODE:	91007
CAPACITY:	200	CENSUS: 72	DATE:	07/08/2021
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Virgilio Agas, Administrator		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Facility failed to report incident to Long term care ombudsman after residents engaged in physical altercation with each other.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA) Tao, conducted an unannounced 10 day complaint visit to this facility. Upon arriving at the facility, LPAs met with Administrator, Virgilio Agas. LPAs explained the purpose of today’s visit is to discuss the above mentioned allegation.

The investigation consisted of resident interviews, staff interviews, resident file review and in-serving training review.

In regard to the allegation: Facility failed to report an incident to Long term care ombudsman after residents engaged in physical altercation with each other.

During today's visit, LPAs interviewed the Staff and Residents. Resident, victim, did not recall details regarding the incident. Two (2) out of four (4) residents stated they did not aware of any resident engaged in a fight. (-continued in LIC 9099 C-)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210629124250

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/08/2021

NARRATIVE

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One (1) out of four (4) residents denied the incident. Per training reviews, staff were trained on de-escalation when providing care. Staff reported the incident to administrator immediately. Administrator reported it to Licensing on the same day. Based on reviewing file, administrator had filed the incident to LA county ombudsmen on 6/24/2021. Therefore, the incident was reported to ombudsman.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

An exit interview was conducted with Administrator. A hard copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2021

LIC9099 (FAS) - (06/04)

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