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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603401
Report Date: 03/23/2023
Date Signed: 03/23/2023 11:29:11 AM


Document Has Been Signed on 03/23/2023 11:29 AM - 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 VILLAGEFACILITY NUMBER:
198603401
ADMINISTRATOR:VIRGILIO AGASFACILITY TYPE:
740
ADDRESS:607 WEST DUARTE RDTELEPHONE:
(626) 447-6070
CITY:ARCADIASTATE: CAZIP CODE:
91007
CAPACITY:200CENSUS: 78DATE:
03/23/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Gil Agas - AdministratorTIME COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analyst (LPA), Ashley Calderon and Erik Zaragoza conducted an unannounced Case Management visit. Purpose of the visit was to address deficiencies observed on 1/19/2023 during a complaint investigation. LPA met with Administrator Gil Agas and stated the purpose of the visit.

LPA's conducted a tour alongside with Mr.Agas. During the visit the following was observed:
  • LPA's observed ceiling tiles to have water damage/ water marks, bubble in ceiling from water build up, cracks and buckets under tiles to retain water when leaking occurs. Ceiling's disrepair in first floor hallway ceiling, tile outside the kitchen, second floor resident room number 214,217, 218, 228 and third floor room number 304.
  • LPAs and Mr. Agas observed first floor medication room and resident room number 304 to have smoke detectors in disrepair. LPA collected supporting documentation, on estimate for smoke detector replacement.
  • LPA Calderon interviewed resident #1 (R1) and resident #2 (R2) both who stated leaking still occurs.
  • LPA interview staff Gil, Business Manager Justin Lee and Facility Contractor, all stated roofing work is still needed.


Deficiency was cited under California Code of Regulations, refer 809-D

An exit interview was conducted a copy of this report and appeal rights were provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley CalderonTELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 03/23/2023 11:29 AM - 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: 03/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/24/2023
Section Cited

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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:
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Licensee/Administrator will provide LPA pictures in 24 hours of tile replacements in the kitchen hallway, tile replacement in Room 228 and will provide estimate invoice for a professional roofing company.
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Ceiling in med tech room, tile in hallway near kitchen, resident rooms: #214, 217, 218, 228 and 304 having openings like cracks, holes, water bubbles and water markings. This was observed during tour of the facility by LPAs alongside with Administrator.
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In addition, Administrator will provide LPA pictures of smoke detectors in med room and room 304 replacement by April 7 2023.
And pictures/invoice of roofing completion of all rooms mentioned in report by April 15th 2023.

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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 FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley CalderonTELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2023
LIC809 (FAS) - (06/04)
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