198603401-6-27-2022-28-AS-MVAO-CHCQ8X-20220816115726

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603401
Report Date: 06/27/2022
Date Signed: 06/27/2022 12:10:30 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
05/19/2021 and conducted by Evaluator Elizabeth Ceniceros

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210519165745

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: 70	DATE:	06/27/2022
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Administrator, Virgilio Agas		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Resident sustained injuries while in care.

Facility did not seek timely medical treatment.

Facility did not notify responsible party of injury.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA)/Retired Annuitant (RA) Elizabeth Ceniceros made an unannounced visit to the facility and was greeted by Administrator (Virgilio Agas). The purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations.

The unannounced 10-Day visit was conducted by LPA Bonnie Tao on 05/25/21. The investigation consisted of the following: LPA Tao interviewed Staff #1 – Staff #5 (including Administrator). LPA Tao interviewed Resident #2 – Resident #7. LPA Tao obtained Staff and Residents’ rosters and requested pertinent documents: Resident #1’s files: Pre-Appraisal Plan, Admission Agreement, Power of Attorney, Emergency and Identification Info, Physician’s Report, Appraisal/Needs and Services Plan, SIRs (dated 04/23/22, 05/17/22, 05/18/22); E-mail communication with Power of Attorney/Responsible Person (dated 05/10/21); Staffs’ In-Service Training Logs covering topics; such as: transferring bedridden residents, first-aid protocol, and documenting reported complaints from resident (dated 06/01/21).

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Araceli Ramirez	TELEPHONE: (323) 980-4925
LICENSING EVALUATOR NAME: Elizabeth Ceniceros	TELEPHONE: (916) 264-1579
LICENSING EVALUATOR SIGNATURE:	DATE: 06/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2022

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-20210519165745

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: 06/27/2022

NARRATIVE

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Regarding Allegation #1: this investigation revealed that a family member told Administrator that Resident #1 will have a doctor appointment on 04/23/21; and, family members will take the resident to its doctor’s appointment on 04/23/21. Administrator did not observe bruises on Resident #1's arm before the doctor’s appointment. Staff #4 (Caregiver) informed administrator that family members transferred Resident #1 from the wheelchair to their car, incorrectly. Injury may have happened while the resident’s family members transferred the resident from the facility to the resident’s doctor’s appointment. When Resident #1 returned to facility after its doctor’s appointment, Staff notified Administrator Agas that Resident #1 had a skin tear on her leg upon return. No skin tear was observed - prior to the doctor’s appointment. Administrator Agas spoke to resident’s Responsible Person (via e-mail, dated 05/10/21) regarding the skin tear. Resident complained about the pain on its left arm. Administrator Agas suggested to resident’s Responsible Person to take the resident for medical treatment. Administrator Agas did not have the medical report of when and where the resident was injured.

Based on the evidence gathered and interviews conducted and records reviewed, 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 of NEGLECT/LACK OF SUPERVISION: Resident sustained injuries while in care is found to be UNSUBSTANTIATED.

Regarding Allegation #2: Administrator Agas informed Resident #1’s family member about the resident’s complaint of pain on 04/24/21 (via text). Med Tech gave medication (Tylenol) to the resident for pain. Administrator did not know whether the resident had a fracture. As soon as Administrator Agas was told about the issue by staff and aware of Resident #1's pain issue, Administrator Agas immediately notified Resident #1’s Responsible Person/Power of Attorney on 04/24/22 regarding seeking medical treatment. Administrator Agas suggested to resident’s Responsible Person/Power of Attorney to take Resident #1 to the doctor for an x-ray. Administrator provided LPA Tao with a copy of an e-mail that Administrator e-mailed to resident’s Responsible Person/Power of Attorney (dated 05/10/21), regarding Resident #1 requiring further medical treatment. On 05/10/21, Resident #1’s Responsible Person/Power of Attorney responded (via e-mail) that she would arrange for a medical appointment for Resident #1. Resident #1’s Responsible Person/Power of Attorney transported the resident to the hospital ER on 05/15/21 due to Resident #1’s bruised left arm (photos) and complaint of pain.

Based on the evidence gathered and interviews conducted and records reviewed, although the allegation

SUPERVISOR'S NAME: Araceli Ramirez	TELEPHONE: (323) 980-4925
LICENSING EVALUATOR NAME: Elizabeth Ceniceros	TELEPHONE: (916) 264-1579
LICENSING EVALUATOR SIGNATURE:	DATE: 06/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20210519165745

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: 06/27/2022

NARRATIVE

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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 of NEGLECT/LACK OF SUPERVISION: Facility did not seek timely medical treatment is found to be UNSUBSTANTIATED.

Regarding Allegation #3: this investigation revealed that Administrator Agas notified Resident #1’s Responsible Person/Power of Attorney on 04/24/21 regarding resident's complaint of pain on its left arm. Administrator spoke to the other family member about the resident’s arm pain. Administrator Agas advised this family member to take Resident #1 to see the hospital’s ER doctor on 05/10/21. Administrator Agas stated that the facility did not get a response from this other family member. On 05/14/21, Administrator Agas text Responsible Person/Power of Attorney about resident's bruised left arm. Resident #1's Responsible Person/Power of Attorney responded (via text message) that she will schedule a doctor’s appointment for Resident #1. On 05/15/21, Responsible Person/Power of Attorney came to pick up Resident #1. Administrator Agas did not know Resident #1's whereabouts after Responsible Person/Power of Attorney picked up Resident #1. On 05/18/21, Administrator Agas text Responsible Person/Power of Attorney to follow up on Resident #1's situation; and, Responsible Person/Power of Attorney text “in the hospital” (SIRs dated 05/17/21, 05/18/21). Resident #1 did not return to the facility and Responsible Person/Power of Attorney requested a refund of the rent covering 05/16/21 to 05/31/21. On 05/25/21, facility reimbursed Resident #1's Responsible Person/Power of Attorney.

Based on the evidence gathered and interviews conducted and records reviewed, 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 of NEGLECT/LACK OF SUPERVISION: Facility did not notify responsible party of injury is found to be UNSUBSTANTIATED.

An exit interview has been conducted and a copy of the Complaint Report provided to Administrator (Virgilio Agas).

SUPERVISOR'S NAME: Araceli Ramirez	TELEPHONE: (323) 980-4925
LICENSING EVALUATOR NAME: Elizabeth Ceniceros	TELEPHONE: (916) 264-1579
LICENSING EVALUATOR SIGNATURE:	DATE: 06/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2022

LIC9099 (FAS) - (06/04)

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