198603401-1-19-2023-28-AS-RORN-CPBVTP-20230223154329

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603401
Report Date: 01/19/2023
Date Signed: 01/19/2023 03:07:28 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
01/11/2023 and conducted by Evaluator Ashley Calderon

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230111104638

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:	09:25 AM
MET WITH:	Gil Agas - Administrator		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Facility is in disrepair.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ashley Calderon conducted an unannounced complaint visit to the facility. Upon arrival, LPA met Gil Agas, Administrator and explained the purpose of the visit.

During today's visit, the investigation consisted of the following: LPA Calderon obtained resident roster and staff roster. LPA Calderon conducted physical plant tour with Gil, observed hallways, observed resident's rooms. Room number(s): 212,215,217,220, 228 and 304. Interviewed Administrator, Staff#1-6 (S1-S6) and interviewed Resident #1-#8 (R1-R8). In addition,LPA Calderon interviewed Social Worker who was visiting facility and interviewed Contractor for flooring who later during LPA's visit stopped by at the facility.

In regard to allegation, Facility in disrepair. Based on Interviews with Resident's 6 out of 8 stated that they have observed ceiling leaking and are aware of leaking when it rain. Interviews conducted with 7 out of 8 residents stated having the floor located on the first floor to be a risk for resident's in care and flooring having cracks, tiles lifting, and needing to be cautious in that area. (Continuation on LIC 9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
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-20230111104638

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: 01/19/2023

NARRATIVE

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Based on interviews, Administrator Gil and staff, 5 of 6 staff stated there is water coming from ceiling in certain areas at the facility also causing damage to the floors. In regards to flooring Gil and 6 out of 6 staff stated floor is not in good repair and needs to be fixed.

Interview with Social Worker stated they informed Administrator about R1's room ceiling over a month ago and ceiling having cracks and holes creating causing water to enter posing as a healthy and safety to resident. LPA interview with Contractor who is appointed to repair flooring states flooring has an issue and company will work on fixing damage floor. In addition, LPA Calderon observed ceiling tiles and floor tiles having holes, cracks and missing pieces. Ceiling tiles in disrepair were observed in first floor hallway, resident's rooms and medicine tech room. Floor tiles on the first floor heading to cafeteria was in despair posing a safety and health hazard to resident's in care.

Based on LPA’s observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be Substantiated and the California Code of Regulations, Title 22, Division 6, Chapter 8 is being cited on the attached LIC 9099-D. LPA issued Civil Penalty on LIC421FC.

Exit interview conducted and a copy of this report and Appeals Rights was provided to Administrator Gil Agas.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
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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Control Number 28-AS-20230111104638

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: 01/19/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/19/2023 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303(a) Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met as evidenced by: hallways flooring having cracks and lifted tile causing immediate risk to residents.	1 2 3 4 5 6 7	Licensee/Administrator will provide LPA pictures of floor being secured using material needed to ensuring cracks, gaps and material are secured and provide invoice rendered by the POC due date of 01/20/2023. that hallway floors tiles and ceiling tiles are repaired as well as resident rooms that have ceiling issues and to maintain facility in clean, safe and in good repair at all times. Ceiling inspection, new roofing material invoices and pictures will be sent to LPA.
	8 9 10 11 12 13 14	Ceiling in med tech room, hallways and resident rooms: #217, 218 and 304 having cracks, openings / holes and water bubbles forming. This was observed during tour of the facility by LPA alongside with Administrator.	8 9 10 11 12 13 14	Provide LPA pictures/ receipts /invoices obtaining detail of materials used and/or labor/services. Floor tiles will be replaced within 30 days as well as ceiling and roofing replaced.
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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: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023

LIC9099 (FAS) - (06/04)

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