198603401-1-19-2023-28-AS-RORN-CNLQPW-20230131112123

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603401
Report Date: 01/19/2023
Date Signed: 01/19/2023 01:13:11 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
01/13/2023 and conducted by Evaluator Alma Gonzalez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230113135700

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: 80	DATE:	01/19/2023
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Virgilio Agas		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Staff spoke inappropriately to resident in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced complaint visit to gather information pertaining to the above-mentioned allegation. LPA met with Administrator Virgilio Agas and explained the reason for the visit.

The investigation consisted of: LPA conducted interviews with Administrator Virgilio Agas, Staff 1-4, and Resident 1-7 (R1-7). LPA obtained copies of Staff and Resident Rosters. LPA reviewed R1's facility file and collected copies of the following documents: Identification and Emergency Information, Physician's Report for Residential Care Facilities for the Elderly (RCFE), Preplacement Appraisal Infromation, Individual Service Plan, and Unusual Incident/ Injury Reports dated 11/10/22, 6/23/21 and 6/25/21.

(See LIC9099C for continuation)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023

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-20230113135700

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ARCADIA RETIREMENT VILLAGE	FACILITY NUMBER: 198603401
	VISIT DATE: 01/19/2023

NARRATIVE

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Investigation revealed the following: Regarding allegation, Staff spoke inappropriately to resident in care, it is alleged that a facility staff speaks inappropriately to and makes inappropriate comments to facility residents (R1). Interviews conducted with 5 out of 5 staff revealed that the facility staff do not make inappropriate comments to facility residents and do not speak inappropriately to facility residents. Interviews conducted with 6 out of 7 residents revealed that the facility have not made inappropriate comments or spoken to them inappropriately. 1 resident stated that one staff in particular has made inappropriate comments and has spoken to them in an inappropriate manner. 6 out of 7 interviewed residents did not have any concerns, stated thatt they are satisfied with the services they receive at the facility and stated that staff treat them with respect and do not speak and/ or treat them inappropriately. Based on interviews conducted with facility staff, and facility residents, there was not enough supportive evidence to concur with the reported allegation.

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.

Exit interview held. A copy of the report was provided to Administrator Virgilio Agas.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023

LIC9099 (FAS) - (06/04)

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