198603401-2-24-2023-28-AS-RORN-CPQPYC-20230308104344

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603401
Report Date: 02/24/2023
Date Signed: 02/24/2023 01:51:18 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
02/23/2023 and conducted by Evaluator Bonnie Tao

COMPLAINT CONTROL NUMBER: 28-AS-20230223163425

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
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Virgilio Agas, administrator		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Facility washer is in disrepair.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tao conducted an unannounced 10-day complaint investigation for the allegation listed above today. LPA met Administrator, Gil Agas and explained the purpose of today's visit.

The investigation consisted of interviews of staff from staff#1 (R1) to staff#2 (R2); interview of resident#1 (R1); obtain of resident roster and staff roster; and tour of the facility.

In regard of allegation, “facility washer is in disrepair,” it was alleged that two (2) washers for residents’ use were broken. The investigation revealed that, per staff interviews and facility tour, two (2) resident's washers was not operable and had not been working for a period of time. At the meantime, facility offered laundry services weekly to all residents to take care of their laundry. Per file review, laundry services were provided to residents. Thus, resident's washers at the facility are in disrepair.

(-continued in LIC 9099 C-)

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: 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.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20230223163425

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: 02/24/2023

NARRATIVE

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Based on LPA's observations, record reviews and interviews conducted the preponderance of evidence standard has been met, therefore the above allegations are found SUBSTANTIATED.

Deficiencies are being cited according to California Code of Regulations, Title 22, Division 6, Chapter 8 on LIC 9099D.

An exit interview was conducted with Administrator, Gil. A hard copy of this report and appeal right were 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

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20230223163425

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: 02/24/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/09/2023 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met by evidence of:	1 2 3 4 5 6 7	Licensee agrees to repair or replace the two washers that are not working. Submit proof of repairs, and/or service invoice, or purchases by POC due date
	8 9 10 11 12 13 14	Two (2) washers for residents’ use were broken. Based on interviews and observation, the Licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
	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: 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

LIC9099 (FAS) - (06/04)

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