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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603401
Report Date: 01/02/2025
Date Signed: 01/02/2025 10:48:51 AM

Document Has Been Signed on 01/02/2025 10:48 AM - 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:
01/02/2025
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:Staff#1, staff in charge
Justin Lee, administrator assistant		TIME VISIT/
INSPECTION COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Tao conducted an unannounced Case Management- Health and safety check visit at the facility. LPA met with Staff#1 (S1), staff in charge and Justin joined the visit at around 10:30am. The purpose of today's visit was explained to them.

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

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

No deficiencies were observed and cited during this visit. Exit interview was held with Justin. This report LIC 809 was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 01/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/02/2025
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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