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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603401
Report Date: 09/08/2022
Date Signed: 09/08/2022 05:24:47 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
05/17/2022 and conducted by Evaluator Bonnie Tao
COMPLAINT CONTROL NUMBER: 28-AS-20220517144134
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
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator, Agas Virgilio
Administrator Assistant, Justin Lee		TIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff did not assist resident.
Untrained staff giving residents medication.
INVESTIGATION FINDINGS:
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***This report serves as an amendment and supersedes the original complaint investigation report created on 05/23/2022. The purpose of this amended Licensing report is to clarify staff interview from the original complaint. The findings changed to substantiated. ***

On 05/23/22, Licensing Program Analyst (LPA) Tao conducted an unannounced initial 10 days complaint investigation and addressed the above allegations. LPA met with Administrator, Agas Virgilio, and Administrator Assistant, Justin Lee. Today 9/8/22, Licensing Program Analysts (LPAs) Tao and Ramirez conducted a subsequent complaint investigation and addressed the above allegations. LPA met with Administrator, Agas Virgilio, and Administrator Assistant, Justin Lee. LPA explained the purpose of today's visit to Agas and Justin.

Investigation consisted of the following: interviews of staff from Staff #1 (S1) through Staff #3 (S3); interviews of residents from Resident #1 (R1) through Resident#8 (R8); reviewed Resident#1’s record reviews, and a facility tour. (-Continued in LIC 9099 C-)
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: 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.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 28-AS-20220517144134
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: 09/08/2022
NARRATIVE
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***This report serves as an amendment and supersedes the original complaint investigation report created on 05/23/2022. The purpose of this amended Licensing report is to clarify staff interview from the original complaint. The findings changed to substantiated. ***

LPAs obtained copies of the staff and resident rosters; and resident#1 files with relevant information.
The investigation revealed the following:

In regard to allegation: “Staff did not assist resident," it was alleged that resident#1 did not get PRN medication from staff after hours. Eight (8) residents were interviewed. Interview with resident #1 revealed that staff did not bring resident any medication after hours. Seven (7) out of eight (8) residents could not corroborate the allegation. Interviewed with Staff#2 and Staff #3 revealed staff did not assist resident#1 with medication after hours. Therefore, interviews revealed staff did not provide medication assistance to resident.
In regard to allegation: “untrained staff giving residents medication," it was alleged that staff#2 did not get medication training as staff#2 handled and dispensed medication to residents. Interviews with staff #1 and staff#2 revealed that staff#2 did not receive training on handling medication as staff#2 dispensed and assisted residents with medication. Staff#2 stated staff had experience dispensing medication prior to 5/15/22. LPA reviewed staff#2 files and did not find medication training records.

Based on review of documents 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.

An exit interview was conducted with administrator. A hard copy of this report and appeal rights were provided to administrator.
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
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20220517144134
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: 09/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/09/2022
Section Cited
CCR
87464(f)(4)
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Personal assistance and care as needed by the resident …such as dressing, eating, bathing and assistance with taking prescribed medications.

This requirement was not met by evidence of:
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Licensee will review Title 22 Regulations,
Section 87464 and submit a written plan detailing how Licensee would ensure that Licensee will follow regulations by POC due date.
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Staff did not dispense Resident#1's medication on 5/15/22. Based on interviews and observation, the Administrator did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
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Type B
09/09/2022
Section Cited
CCR
87411(d)
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Personnel Requirements – General (d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training...shall provide knowledge of and skill... as evidenced by safe and effective job performance.
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** This citation was cleared on 5/31/22**
Licensee will review Title 22 Regulations, Section 87411 and submit a written plan detailing how he will ensure that staff are receiving the required in-service trainings according to the Regulation. Licensee must also conduct an in-service training to
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This requirement is not met as evidenced by:

Staff#2 did not receive in-service and job training on handling medication.

This poses a potential health and safety risk to person's in care.
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Staff #2 on handling medication and to all staff in reference to Section 87411. Liceness will provide a copy of names and signatures of all staff in attendance of trainings. POC is due to CCL by 05/31/22
** This citation was cleared on 5/31/22 from the initial complaint visit on 5/23/22**
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
LIC9099 (FAS) - (06/04)
Page: 3 of 3