198603401-9-14-2022-28-AS-RORN-CJQV72-20220929161026

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603401
Report Date: 09/14/2022
Date Signed: 09/14/2022 04:57:30 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
09/09/2022 and conducted by Evaluator Bonnie Tao

COMPLAINT CONTROL NUMBER: 28-AS-20220909103443

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: 78	DATE:	09/14/2022
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Administrator, Agas Virgilio		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Facility staff failed to provide resident with updated prescription and medication as prescribed.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tao conducted unannounced complaint investigation for the allegation listed above today. During today’s visit, LPA met Administrator, Gil Agas. LPA explained the purpose of today's visit regarding the above-mentioned allegation.

Investigation consisted of the following: interviews of staff from Staff #1 (S1) through Staff #6 (S6); interview of Resident#1 (R1); reviewed resident#1’s record reviews, and a facility tour. LPA obtained copies of the Staff and Resident Rosters; and resident files for Resident #1 (R1) with relevant information.

In regard of the allegation, “Facility staff failed to provide resident with updated prescription and medication as prescribed”, it is alleged that resident#1's prescription was not updated, and resident#1's medication was not administered as prescribed after discharged from hospital. The investigation revealed the following.

(-continued in LIC 9099 C-)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022

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-20220909103443

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: 09/14/2022

NARRATIVE

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Interviewed with resident#1, resident could not corroborate the allegation. Resident interview revealed that resident was not aware of change of prescription or medication from resident’s primary doctor. Six (6) out of six (6) staff denied the allegation. Staff interviews, including interviews of pharmacies and primary doctor, revealed resident’s prescription did not need to change and would continue July prescription when finished medication supply from hospital pharmacy in August. File review revealed R1 would continue July prescription in September. During resident interview, LPA did not observe issues or resident complained about resident’s medication. Therefore, resident’s prescription remained and dispensed as prescribed.

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 is UNSUBSTANTIATED.

No deficiencies are being cited according to California Code of Regulations, Title 22, Division 6, Chapter 8.

An exit interview was conducted with Administrator. A hard copy of this report was provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022

LIC9099 (FAS) - (06/04)

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