198603401-5-5-2022-28-AS-LHIS-CEHMMJ-20220517094402

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603401
Report Date: 05/05/2022
Date Signed: 05/05/2022 04:33:01 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
04/29/2022 and conducted by Evaluator Jewel Baptiste

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220429164803

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: 78	DATE:	05/05/2022
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Administrator, Virgilio Agas		TIME COMPLETED:	04:40 PM

ALLEGATION(S):

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Staff are not providing adequate food service to residents

INVESTIGATION FINDINGS:

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On 5/5/22 at 10:30 a.m., Licensing Program Analyst (LPA) Jewel Baptiste, conducted an unannounced 10-day complaint visit to this facility. Upon arriving at the facility, LPA met with Administrator Agas Virgilio and Assistant Administrator Justin Lee. LPA explained the purpose of today’s visit is to discuss the above-mentioned allegation.

Prior to this visit, LPA reviewed videos and photos from complainant of rodent infestation. LPA conducted file review and observed a complaint for rodent infestation was substantiated on 2/24/22.
LPA toured the facility with administrator and assistant administrator, conducted staff, resident and exterminator interviews, review facility exterminator record, and obtain staff and resident rosters.

Report continued on 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel Baptiste	TELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2022

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 5

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
04/29/2022 and conducted by Evaluator Jewel Baptiste

COMPLAINT CONTROL NUMBER: 28-AS-20220429164803

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: 78	DATE:	05/05/2022
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Administrator Virgilio Agas		TIME COMPLETED:	04:40 PM

ALLEGATION(S):

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Facility has rodents

INVESTIGATION FINDINGS:

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On 5/5/22 at 10:30 a.m., Licensing Program Analyst (LPA) Jewel Baptiste, conducted an unannounced 10-day complaint visit to this facility. Upon arriving at the facility, LPA met with Administrator Agas Virgilio and Assistant admistrator Justin Lee. LPA explained the purpose of today’s visit is to discuss the above-mentioned allegation.

Prior to this visit, LPA reviewed videos and photos from complainant of rodent infestation. LPA conducted file review and observed a complaint for rodent infestation was substantiated on 2/24/22.

LPA toured the facility with administrator and assistant administrator, conducted staff, resident and exterminator interviews, review facility exterminator records, and obtain staff and resident rosters.

Report continued on 9099c

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel Baptiste	TELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2022

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

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 28-AS-20220429164803

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: 05/05/2022

NARRATIVE

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The investigation reveals the following:

Regarding "Facility has rodents" it is alleged that facility has a rodent infestation. During the tour LPA did not observe live rodents at the facility. 4/5 Staff interviewed confirmed rodents was observed in the facility but they have not seen any since the exterminator company has serviced the facility. 1 Staff interview confirmed they have heard mice on the roof. 1 resident interview confirmed they have not seen any rodents. Administrator confirmed that exterminator service facility once a month. Review of Exterminator service inspection report dated on 4/12/22 confirmed rodents, insects and pests. Exterminator service report stated targeted areas and problems and solutions for disposing of pest problems. Exterminator interview revealed that they can not clear physical plant of rodents and has seen improvements since servicing. Exterminator recommendation is to increase service for kitchen until rodent infestation is cleared.

Based on review of documents and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22. Civil penalties issued for repeated violation.

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

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel Baptiste	TELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 28-AS-20220429164803

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/05/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/05/2022 Section Cited CCR 80087(a)(1)	1 2 3 4 5 6 7	Buildings and Grounds 80087(a)(1) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (1) The licensee shall take measures to keep the facility free of flies and other insects. This requirement was not met by evidence of:	1 2 3 4 5 6 7	Administrator will continue to schedule regular exterminator treatment, and ensure that facility is completely cleared of rodent problem. Adminstrator will follow extenminator recommendations and submit monthly exterminator summary to CCLD by POC due date.
	8 9 10 11 12 13 14	Based on observation and interviews conducted, facility has rodent. Staff interviews has confirmed rodent problem. Exterminator can not clear facility grounds of rodents. LPA observed rodent droppings in kitchen and private dinning room. which poses a potential health, safety, or personal rights risks to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Lisa Hicks	TELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel Baptiste	TELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2022

LIC9099 (FAS) - (06/04)

Page: 5 of 5

Control Number 28-AS-20220429164803

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: 05/05/2022

NARRATIVE

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The investigation reveals the following:
Regarding “Staff are not providing adequate food service to residents” it is alleged that staff serve food that has been contaminated by rodents. During tour of the kitchen and pantry LPA observed droppings in container with packaged crackers. 6/6 Staff interviews revealed that they have not seen droppings in the food and if they notice any droppings they will dispose of the food right away. During the tour staff disposed of the droppings in the container of crackers.

Based on LPA's interviews, investigation revealed: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted with Administrator Virgilio Agas and a copy of this record provided

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel Baptiste	TELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 5