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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603401
Report Date: 04/07/2021
Date Signed: 04/08/2021 11:58:02 AM

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
04/02/2021 and conducted by Evaluator Bonnie Tao
COMPLAINT CONTROL NUMBER: 28-AS-20210402112024
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: 60DATE:
04/07/2021
UNANNOUNCEDTIME BEGAN:
02:33 PM
MET WITH:Virgilio Agas, AdministratorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff leave medications unattended.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tao initiated a complaint investigation for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Administrator.

LPA Tao conducted telephone interviews with Staff #1, Staff #2, and Staff #4. LPA obtained Resident roster, Staff roster and a short video recorded medication was unattended. LPA requested the following records: Staff’s in-service training log on handling medication, job description of Med Tech and job description of Caregiver.

Based on LPA observations and interviews 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.

A telephonic exit interview was conducted with Administrator. A copy of LIC 9099 and appeal rights were provided via email for signature.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2021
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 3
Control Number 28-AS-20210402112024
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: 04/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/08/2021
Section Cited
CCR
87465(h)(2)
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(h)(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement was not met by evidence of:
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Licensee will ensure that medications are monitored, medication cart is locked, med cart keys are not inserted in the lock keyhole. and ensure residents do not have access. Licensee will submit written documentation to CCL on how they will ensure this would not happen in the future by POC due date.
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LPA reviewed a short video that showed a medication cart was unattended in the facility hallway and key was inserted in the keyhole of the lock. This poses an immediate health and safety risk to residents.
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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 FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3