198603401-8-23-2021-28-AS-FFIS-CF5V38-20220606160420

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603401
Report Date: 08/23/2021
Date Signed: 08/23/2021 05:30:46 PM

Substantiated

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
08/16/2021 and conducted by Evaluator Bonnie Tao

COMPLAINT CONTROL NUMBER: 28-AS-20210816142932

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: 74	DATE:	08/23/2021
		UNANNOUNCED	TIME BEGAN:	11:02 AM
MET WITH:	Justin Lee, Adminstrator assistant		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Facility has bed bugs.

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 Assistant, Justin Lee and spoke with Administrator Gil Agas over the phone. LPA explained the purpose of today’s visit is to discuss the above mentioned allegation.

In regards to the allegation: Facility has bed bugs. LPA reviewed pest control invoice and spoke with pest control company, both stated the facility received bedbug treatment on August 10, 2021. LPA spoke with administrator and confirmed the facility had bedbug issue on August 10, 2021.

Based on LPA interview which were conducted and record reviews, the preponderance of evidence standard has been met, therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 & Chapter 8, are being cited on the attached LIC 9099D.

Exit interview conducted and a copy of this report provided to Administrator assistant, Justin Lee
(- continued in LIC 9099 A-)

Substantiated

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: 08/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2021

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 4

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
08/16/2021 and conducted by Evaluator Bonnie Tao

COMPLAINT CONTROL NUMBER: 28-AS-20210816142932

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: 74	DATE:	08/23/2021
		UNANNOUNCED	TIME BEGAN:	11:02 AM
MET WITH:	Justin Lee, Adminstrator assistant		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Facility did not safeguard resident's belongings.

Facility did not ensure that resident had clean clothing to wear.

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 Assistant, Justin Lee and spoke with Administrator Gil Agas over the phone. LPA explained the purpose of today’s visit is to discuss the above mentioned allegations.

In regards to the allegation: Facility did not safeguard resident's belongings.
LPA interviewed the Administrator, Staff #2-#5, Resident #1 - #6, obtained a copy of resident#1 agreement/note related to bedbug fumigation on 8/10/21. Interviews indicated that Resident #1 was informed and agreed about the removal of items with bedbugs prior to fumigation. Interviews with residents #1 - #6 and Staff #2-#5 revealed that staff safeguard residents’ belongings.

Based on LPA's observations and interviews, investigation revealed: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. (-contiued 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: 08/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2021

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

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 28-AS-20210816142932

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: 08/23/2021

NARRATIVE

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In regards to the allegation: Facility did not ensure that resident had clean clothing to wear.

LPA interviewed the Administrator, Staff #2-#5, Resident #1 - #6, obtained a copy of resident#1. Admission agreement and physician report. Interviews indicated that Resident #1 has resident’s own housekeeper to do laundry and able to dress herself. Interviews with residents #1 - #6 and Staff #2-#5 revealed that facility ensured resident had clean clothing to wear and laundry was done weekly.

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

Exit interview conducted and a copy of this report provided to Administrator assistant, Justin Lee

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 28-AS-20210816142932

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: 08/23/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/26/2021 Section Cited CCR 80087(a)(1)	1 2 3 4 5 6 7	Buildings and Grounds (a) 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 is not met as evidenced by:	1 2 3 4 5 6 7	Facility has initiated services on 8/10/21 and 8/12/21 from a professional pest control company and fumigated / treated roomn 246 with bedbugs. Facility to submit inspection clearance from pest control to ensure the entire phyicial plant is clear of bedbugs and/or invoice by POC due date.
	8 9 10 11 12 13 14	Administrator and Pest control company confirmed the facility had bedbugs issue on 8/10/21. This poses an immediate Health, Safety, and/or Personal Rights risk to the clients 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: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2021

LIC9099 (FAS) - (06/04)

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