198603401-9-8-2021-28-AS-FFIS-CFSV5L-20220627160808

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603401
Report Date: 09/08/2021
Date Signed: 09/08/2021 02:14:21 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
08/31/2021 and conducted by Evaluator Bonnie Tao

COMPLAINT CONTROL NUMBER: 28-AS-20210831103704

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:	09/08/2021
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Virgilio Agas, Administrator		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Staff threatened resident.

Staff refused to send resident's medical paperwork to resident's primary care physician

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tao conducted an initial unannounced complaint visit to investigate the above allegations. LPA was allowed entry by Administrator. LPA explained the purpose of today's visit.

The following occurred during this investigation: LPA obtained copies of the Staff and Resident Rosters and toured the physical plant. LPA reviewed Resident files for Resident #1 (R1) and obtained relevant information. Between 11:35am- 12:15pm, LPA interviewed Staff #1-#4 (S1-S4) and Residents #1-#6 (R1-R6).

The investigation revealed the following:
In regards to allegation " Staff threatened resident," it was alleged that S1 said to R1 not to file anymore complaint against facility and R1 can leave if R1 does not like the facility. Four (4) out of four (4) staff denied the allegation. Staff interviews revealed residents can file complaint at residents’ will. Five (5) out of six (6) residents could not corroborate the allegation. (- Continued on 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: 09/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2021

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

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210831103704

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: 09/08/2021

NARRATIVE

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Those five residents stated that they can file complaints as they wish. LPA did not observe residents were threaten by staff when they file complaints at the time of visit. 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.

In regards to allegation " Staff refused to send resident's medical paperwork to resident's primary care physician", it was alleged that administrator did not send resident’s medical paperwork to resident’s primary care physician. Four (4) out of four (4) staff denied the allegation. Five (5) out of six (6) residents could not corroborate the allegation. Review of R1's file showed that administrator sent medical paperwork as instructed by hospital’s discharge paperwork. LPA spoke with R1's primary physician staff and confirmed physician did not require nor request to have a copy of medical paperwork. 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.

An exit interview was conducted with Administrator, Gil Agas, and a hard copy was provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2021

LIC9099 (FAS) - (06/04)

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