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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603401
Report Date: 04/18/2022
Date Signed: 04/19/2022 07:36:53 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/29/2021 and conducted by Evaluator Ngozi Nwaokoro
COMPLAINT CONTROL NUMBER: 28-AS-20211129092023
FACILITY NAME:ARCADIA RETIREMENT VILLAGEFACILITY NUMBER:
198603401
ADMINISTRATOR:VIRGILIO, AGASFACILITY TYPE:
740
ADDRESS:607 WEST DUARTE RDTELEPHONE:
(626) 447-6070
CITY:ARCADIASTATE: CAZIP CODE:
91007
CAPACITY:200CENSUS: 74DATE:
04/18/2022
UNANNOUNCEDTIME BEGAN:
01:57 PM
MET WITH:Virgllio AgasTIME COMPLETED:
02:28 PM
ALLEGATION(S):
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Allegation: Staff is not Providing Adequate Supervision.



INVESTIGATION FINDINGS:
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12/01/2021, Licensing Program Analyst (LPA) Tao initiated a complaint investigation for the allegations listed above. LPA met Administrator, Virgilio Agas upon arrival.
The investigation consisted of the following: Staff #1, and Resident #1 to Resident #3 were interviewed.
A physical plant tour of the facility was conducted. Resident#1 file review was conducted. LPA obtained a copy of resident roster, staff roster, R1's Emergency Information (Face Sheet), R1's physician report, R1's Pre-Placement Appraisal, R1's Needs and service plan, R1’s Admission agreement. A hard copy of the report was provided to Administrator.

On 4/18/2022 LPA Ngozi Nwaokoro conducted a supplemental visit that consisted of a facility tour and interviews with staff and residents. LPA obtained a current resident roster and staff roster.

Continued in LIC 9099 C


Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 918-3347
LICENSING EVALUATOR NAME: Ngozi NwaokoroTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 28-AS-20211129092023
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: ARCADIA RETIREMENT VILLAGE
FACILITY NUMBER: 198603401
VISIT DATE: 04/18/2022
NARRATIVE
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The complainant alleges that Resident (R1) stated that staff is not providing adequate supervision. According to the complainant, RP spoke to the Administrator who confirmed that a staff member recently reported to him that the alleged resident was seen going to other residents’ rooms. RP asked what steps the facility was taking to keep other residents safe and the administrator stated that the alleged resident will be evicted from the facility.

LPA Nwaokoro reviews residents’ documents and interview residents and staffs and the following was revealed:

Resident 1-5 (R1- R5) were interviewed and revealed the following: R1 stated that they get their medications at the right time, but R1’s issue now is the food, “The food was tasty before, not now”. “Their soup is not sweet and chicken not spicy”. R2 stated that the facility provides adequate supervision, stating that “it is easy to access staff in the facility”. R3 also affirmed that the facility provides adequate supervision however, R3 concern is the food, “Too much chicken, they can add Hotdog and Hamburger to the menu”. R4 responded that their needs are met and R4 do not have concern with caregiver’s supervision. R5 also confirms liking services provided by caregivers and not having any concerns with supervision.

Staff 1-5 (S1- S5) were interviewed and revealed the following: The Administrator stated that residents are supervised to the best of his ability, stating that staff are reminded to meet residents needs as these residents are their bosses, resident pay the facility and it’s the responsibility of the facility to ensure residents safety. On allegation that food is not tasty, the administrator acknowledged the concern and stated that efforts are on to hire new cooks and to make changes in resident menu.

S1 said she has worked in the facility for three years, the only time caregivers have issues with residents is during shift transfer, a resident maybe waiting, but after shift transfer, caregivers ensure all resident’s needs are met. S2 denied the allegation that staff do not provide adequate supervision, stating that “if caregivers are busy, the med tech attends to their needs.” S3 affirmed that caregivers try their best to keep residents happy and have not heard any resident complaining. S4 also affirmed that caregivers always assisted resident and ensure they are safe. S4 have not heard any resident complained of services rendered by caregivers. S5 is concerned about a resident that is aggressive towards staff. Apart from that, S5 stated that caregivers assist all the residents as quickly as possible.
SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 918-3347
LICENSING EVALUATOR NAME: Ngozi NwaokoroTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20211129092023
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: ARCADIA RETIREMENT VILLAGE
FACILITY NUMBER: 198603401
VISIT DATE: 04/18/2022
NARRATIVE
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Based on LPA observations, and review of documents and interviews conducted. Although the allegation may have happened or is valid, there is not preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.
SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 918-3347
LICENSING EVALUATOR NAME: Ngozi NwaokoroTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3