198603401-9-8-2022-28-AS-FFIS-CJRRA5-20220930125031

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603401
Report Date: 09/08/2022
Date Signed: 09/08/2022 05:19:25 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
06/28/2022 and conducted by Evaluator Bonnie Tao

COMPLAINT CONTROL NUMBER: 28-AS-20220628165933

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: 77	DATE:	09/08/2022
		UNANNOUNCED	TIME BEGAN:	03:45 PM
MET WITH:	Administrator, Agas Virgilio Administrator Assistant, Justin Lee		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Unqualified staff administrating medication.

INVESTIGATION FINDINGS:

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Substantiated

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: 09/08/2022

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)

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Control Number 28-AS-20220628165933

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 07/01/2022. The purpose of this amended Licensing report is to clarify the allegation from the original complaint. The finding remains as substantiated. ***

In regard to allegation, “unqualified staff administrating medication," it was alleged that staff#2 family member (son), volunteer#1(V1), worked in the facility for one day by assisting a resident with medications. Resident#1 interview revealed that V1 handed over the medication from a Med tech's hand to R1. Medication was in a container cup and prepared by Med Tech. Staff took over the medication and administered resident's medication right after. Resident did not miss medication from that incident.

Two (2) out of two (2) staff admitted the allegation and explained that it was a single incident. Staff interviews revealed V1 was assisted to hand out the medication to a resident. File review revealed R1 did not miss medication from that incident. Incident report regarding the incident was provided. During the visit, LPA did not observe unqualified staff passing medication to residents.

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. A hard copy of this report and LIC 9099D were provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (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)

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Control Number 28-AS-20220628165933

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 B 09/14/2022 Section Cited CCR 87411(d)	1 2 3 4 5 6 7	(d) All personnel shall be given on the job training or have related experience in the job assigned to them..shall provide knowledge of and skill...for the job assigned and as evidenced by safe and effective job performance. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee will review Title 22 Regulations, Section 87411 and submit a written plan detailing on (1) how licensee will ensure that staff are receiving the required in-service trainings according to the Regulation and providing care and supervision by the POC due date.
	8 9 10 11 12 13 14	Visitor#1 (V1) did not have knowledge to provide care and supervision. This poses a potential health and safety risk to person's in care.	8 9 10 11 12 13 14	This citation was cleared on 7/1/22 from the initial complaint visit
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (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)

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