198603401-2-18-2021-28-AS-BTAO-BYD44C-20210218174608

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603401
Report Date: 02/18/2021
Date Signed: 02/18/2021 05:48:17 PM

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 VILLAGE		FACILITY NUMBER:	198603401
ADMINISTRATOR:	VIRGILIO, AGAS		FACILITY TYPE:	740
ADDRESS:	607 WEST DUARTE RD		TELEPHONE:	(213) 700-1758
CITY:	ARCADIA	STATE: CA	ZIP CODE:	91007
CAPACITY:	200	CENSUS: 62	DATE:	02/18/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Virgilio Agas, Administrator Justin Lee, Assist Administrator Dr. Shin Wook Kang, Applicant		TIME COMPLETED:	01:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA), Tao conducted an announced pre-licensing inspection. An application was submitted to CCLD on 12/17/20 for a change of ownership. LPAs met Virgilio Agas, Administrator, Justin Lee, Assistant Administrator, and Shin Wook Kang, licensee applicants, at the virtual visit. The applicant is Goldwater Sag Holdings, LLC. The facility was previously licensed to Goldwater Sag Holdings, LLC with facility # 198602098. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s inspection was conducted telephonically with Applicant. Applicant applied for Residential Care Facility for the Elderly to serve the Elderly for 60 years and older. The requested capacity is 149 which including 134 non-ambulatory residents and 15 maybe bedridden in rooms #101 thru #119. Facility may have 25 residents with Hospice wavier. Structure: The facility is a stucco structure with 91 bedrooms, 91 bathrooms, 1 TV room, an administrative office, a restaurant style kitchen, a laundry room, a coin laundry room, a janitor storage room, an activity room, a dining room and two elevators. There is a covered patio area on the premises. The resident bedrooms are spacious and will easily accommodate the client's furnishings. Passageways, walkways, stairs and patios are free from obstructions. The entrance and side areas are free of hazards and debris. Signal system: Facility has a signal system. It operates properly. (-continued LIC 809 C -)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 02/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2021

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

LIC809 (FAS) - (06/04)

Page: 1 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 02/18/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Bedrooms for Residents:
Bedroom has a chair, nightstand, adequate lighting, adequate closet and drawer space. Bedrooms are spacious and allow for easy passage between and comfortable for usage of assistant devices such as walkers.
Bathrooms:
All bathrooms have a working toilet, wash basin, bathtub/shower. Bedrooms for non-ambulatory residents are accommodated for residents in a wheelchair.
Linens & Hygiene Supplies:
Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen stored in storage room.
Emergency Phone Numbers, Exit Plan & Menu:
Emergency Disaster Plan is posted at the lobby near the entrance. Menus are available for review.
Free landline telephone and mobile phones are available for residents’ use and operable.
Nineteen fire extinguishers are available in the facility. They are located near kitchen door mounted on wall, hallways of each floor and TV lounge room. They are fully charged and last service was done in December 21, 2020.
Food Service:
Dishes, cups and flat ware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are stored in a locked drawer in the kitchen. Food supply adequate stored and consists of two days of perishable and two weeks of non-perishable. Dishwasher in kitchen properly installed and functioning.
Smoke Detectors:
Smoke detectors are located in residents’ rooms. They are operational and not hard wired. Carbon monoxide detectors located in hallway of each floor and are operational.

(-Continued LIC 809 C -)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 02/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2021

LIC809 (FAS) - (06/04)

Page: 4 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 02/18/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Appliances:
Stove burners, oven, microwave, washer, and dryer working. There are two refrigerators in the kitchen including a walk-in refrigerator and one additional refrigerator for food storage. Each refrigerator has a measured temperature of at least 45 degrees Fahrenheit for appropriate food storage. Freezer is at (0) zero degrees Fahrenheit. The residence is equipped with central air and heat and each client bedroom is individually climate controlled. The temperature is in a range of 68 to 75 degrees Fahrenheit.
Toxins:
Poisons, toxins, and cleaning supplies are locked in a room and inaccessible to residents.
Water Temperature:
Tested at 110. degrees Fahrenheit in room 115 and 110.5 degrees Fahrenheit in the kitchen. Medications, First-Aid Kit & Book:
A first aid kit has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze and current first aid manual, which are stored in administrator office, available for staff use but inaccessible to residents.
Clients & Staff Files:
Applicant will not handle cash resources for residents. Records of staff and clients shall be stored in a locked cabinet in administrator’s office and the section has been inspected along with the available records present. The facility has Liability insurance coverage.
Reading Material, Games, Equipment & Materials:
The facility has board games, books, bingo games, karaoke and other recreational materials for the residents’ use, commensurate with the plan of operation. Due to COVID 19 pandemic, residents are encouraged to have activities in their own room.
Pool:
Facility has no pool. Bodies of water is located at the entrance which is not accessible to residents.

(- Continued LIC 809 C -)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 02/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2021

LIC809 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 02/18/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Fire clearance:
Fire Clearance with 0 ambulatory, 134 non-ambulatory and 15 bedridden was approved on 01/27/2021.
Residents’ bedrooms # 101- #119 are designated for bedridden rooms.

Component III:
Conducted at the Pre-Licensing visit, information provided about how to operate the facility within substantial compliance.

A virtual exit interview was conducted with Administrator, and a hard copy was provided via email for signature.

Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAU Analyst assigned to their application.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 02/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2021

LIC809 (FAS) - (06/04)

Page: 3 of 4