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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603401
Report Date: 08/18/2022
Date Signed: 08/18/2022 03:39:06 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
08/10/2022 and conducted by Evaluator Glenn Trueman
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220810085926
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: 76DATE:
08/18/2022
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Virgilio AgasTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility is not properly addressing issue with rodents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Glenn Trueman conducted a complaint investigation at the facility. Upon arrival, LPA met with Administrator Agas Virgilio and explained the purpose of the visit.
The purpose of the visit is to investigate the allegation listed above.
During today's visit, LPA obtained a copy of the Staff/Resident Roster and toured the kitchen and electrical room with Agas Virgilio and Staff S 1.
At today's visit interviews were conducted with Administrator and S 1 from 12:50 PM to 1:10 PM.
Interviews were conducted from 1:10 PM to 1:30 PM with Staff 2-4.
In regards to the allegation Facility is not properly addressing issue with rodents, based on interviews conducted and information gathered Administrator confirmed that a week ago rodents were observed under the shelf and under the juicer. Confirmed that rodent droppings were observed also on the visit a week ago by Department of Public Health.
Interview conducted with S 1 who confirmed that a dead mouse was found in the dining room on 08/16/2022.



Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn TruemanTELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2022
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-20220810085926
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: 08/18/2022
NARRATIVE
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Interviews conducted with Staff S 2 and S 3 who both confirmed that a dead mouse was found in the kitchen 1 day ago 08/17/2022.
Interview conducted with Staff S 4 who confirmed observing a dead mouse 1 week ago.
Based on observation and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22, Division 6, Chapter 1. See LIC 9099D.

An exit interview was conducted with Administrator.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn TruemanTELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20220810085926
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: 08/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/19/2022
Section Cited
CCR
87303(a)
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Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement was not met as evidenced by:
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Facility to increase frequency of Pest Control
visits to 3x a week for 30 days and 1x a week for the next 30 days to specifically address rodent activity and eradicating mouses .
Facility to submit new schedule from Pest Control Company by POC due date.
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Based on observation, the Licensee did not have the facility clean, safe, sanitary and in good repair at all times with interviews confirming that rodents have been observed in the kitchen and a dead mouse observed 1 day ago which causes an Immediate Health and Safety Risk to Residents In Care.
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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: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn TruemanTELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3