198603401-2-24-2023-28-AS-BTAO-CPD3W6-20230224173613

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603401
Report Date: 02/24/2023
Date Signed: 02/24/2023 05:37:02 PM

Document Has Been Signed on 02/24/2023 05:37 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 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:	02/24/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Virgilio Agas, administrator		TIME COMPLETED:	05:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met with Virgilio (Gil) Agas, administrator, who assisted with visit. The facility is licensed to serve the elderly who are 60 years and older. It has 25 hospice wavier approved. Its capacity is 200 residents including 149 non-ambulatory, of which 15 may be bedridden. Rooms 101-119 are approved for bedridden. Annual fees are current. Administrator certificate is current and the expiration date is 7/14/2023. During the visit, the infection control domain tool was used, a tour of the facility was conducted, food supply was reviewed, medications/staff's files/residents' files were reviewed, and staff and residents were interviewed. The facility is located in a residential neighborhood. It is three-story, stucco structure with 91 bedrooms, 91 bathrooms, 1 TV room, an administrative office, a restaurant style kitchen, a laundry room, a coin laundry room, a janitor storage room, an activity room, a dining room and two elevators. There is a covered patio area on the premises. The resident bedrooms are spacious and will easily accommodate the resident's furnishings. Passageways, walkways, stairs and patios are free from obstructions. The entrance and side areas are free of hazards and debris. A physical tour was conducted. LPA toured Room# 110, 212, 219, 220, 242, 316, 320 and 331. Residents’ rooms were well furnished and in compliance. Bathrooms inspected were clean, operable, with the required grab bars and non-skid materials in the shower. Hot water temperature was in a range of 105.3 to 116.5 degrees Fahrenheit which was within Title 22 Regulation guidelines. (- continued in LIC 809-C -)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023

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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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
	VISIT DATE: 02/24/2023

NARRATIVE

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Adequate linen and personal hygiene supplies was observed. Facility had no pool. Bodies of water
was a fountain (3 ft x 3 ft in size) located at the entrance outdoor which had no water and not in operation. No firearms on the premises. Facility maintained a comfortable temperature for residents. Facility has a signal system and operates properly. LPA tested the signal system, staff responded to the call in one minute and came to the room in around five minutes.

Sufficient supply of perishable and nonperishable foods was observed. Knives, tools, sharp items were inaccessible to residents. Smoke detectors and carbon monoxide detectors were operable. They were not hard wired. Fire extinguishers’ last service was 6/2/22 and are fully charged.

The first aid kit was fully stocked. Mandated documents and signages were posted in common areas.
The outdoor activity area had a shaded patio with ample seating. Medication were centrally stored in
locked medication carts in the medication room and inaccessible to residents. Resident records were
stored in a locked cabinet and inaccessible to residents. Toxic substances were inaccessible to
residents. Outdoor facility space for residents' leisure and use were completely enclosed by a fence
with self-closing gates.

Deficiencies were observed and cited per California Code of Regulations, Title 22 in LIC 809 D.
An exit interview was conducted. This report is discussed and provided to facility Administrator,
whose signature on this form confirm receipt of these documents. A copy of appeal rights was
provided

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/24/2023 05:37 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: 02/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(a)

Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by: Resident room# 320: The flooring near the bathroom is in dis-repaired. Five flooring pieces are loosen and detached. Resident room# 331: The hallway ceiling in front of resident room# 331 (3nd floor) has water leak. Water is leaking from the roof and dripping down from the ceiling to the hallway. Resident room #242: Bathroom has water leak. Water is leaking under the sink
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/03/2023
	Plan of Correction
1 2 3 4	Licensee agrees to (1) repair the roof and ceiling on the 3nd regarding the water leak, (2) repair room 320's flooring, (3) repair room 242's sink and (4) repair or replace call signal in room 212 by the POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 02/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023

LIC809 (FAS) - (06/04)

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