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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603401
Report Date: 09/08/2022
Date Signed: 09/08/2022 05:20:38 PM


Document Has Been Signed on 09/08/2022 05:20 PM - It Cannot Be Edited

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 VILLAGEFACILITY NUMBER:
198603401
ADMINISTRATOR:VIRGILIO, AGASFACILITY TYPE:
740
ADDRESS:607 WEST DUARTE RDTELEPHONE:
(626) 447-6070
CITY:ARCADIASTATE: CAZIP CODE:
91007
CAPACITY:200CENSUS: 77DATE:
09/08/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Administrator, Agas Virgilio
Administrator Assistant, Justin Lee		TIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Tao and Ramirez conducted an unannounced case management visit during a complaint investigation# 28-AS-20220628165933 regarding unqualified staff administrating medication. During today’s visit, LPAs met with Administrator, Agas Virgilio and Administrator Assistant, Justin Lee. LPA explained the purpose of today's visit.

LPA reviewed staff roster and interviewed Administrator. The review and interview revealed that volunteer#1 (V1) was working in the facility while not being cleared and associated to the facility. Administrator stated facility did not allow staff, nor have policy for staff bringing their children to the facility while staff are working. Administrator had discussed with staff after the incident. Staff agreed not to bring children to work again.

Deficiency is being cited according to California Code of Regulations, Title 22, Division 6, Chapter 8, Article 04. See LIC 809D. Civil penalty was cited.

An exit interview was conducted with Administrator, Agas Virgilio. A hard copy of the report and appeal rights was provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/08/2022 05:20 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/15/2022
Section Cited

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Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review.

This requirement is not met as evidenced by:
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Volunteer#1 (V1) was working in the facility while not being cleared and associated to the facility.

This poses a potential health and safety risk to person's 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: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2022
LIC809 (FAS) - (06/04)
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