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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603401
Report Date: 11/01/2021
Date Signed: 11/01/2021 02:15:06 PM



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
10/28/2021 and conducted by Evaluator Christine Wong
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20211028082256
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: 67DATE:
11/01/2021
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Virgilio Agas-AdministratorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff are not adequately trained
Uncleared adult in the facility
Staff did not notify resident's authorized representative of change of pharmacy
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Wong conducted an unannounced complaint visit to investigate the above allegations. LPA met with receptionist- Giselle Provencio and explained the reason for the visit. A short time later, administrator, Virgilo Agas arrived.

The investigation consisted of the following: LPA interviewed six (6) residents, administrator and seven (7) staff. LPA also obtained the resdient roster, staff roster and medication training log. LPA also toured the facility and room#301.

The investigation revealed of the following: Allegation#1 "Staff are not adequtely trained." LPA interviewed residnets and they stated staff are able to meet their needs. LPA interviewed five staff and all reported the caregivers never received any job training for a duty of med-tech. LPA also reviewed the medication-training rosters and caregiers name were not on the trianing log.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 28-AS-20211028082256
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: 11/01/2021
NARRATIVE
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In regard to Allegation#2 "Uncleared adult in the facility." LPA observed two adults in the facility who are not fingerprinted and not associated with the facility and they are currently living in resident room# 301. The owner of the facility also admitted the two adults had been lived in the facility without fingerprint clearance for two months already.

In regard to Allegation#3: "Staff did not notify resident's authorized representative of change of pharmacy." LPA interviewed six (6) residents, four reported that no one ever notified them about the changing of pharmacy. The facility only posted a memo on the wall for notification but did not get any consent from the residents or authorized representatives. LPA interviewed staff and reported the facility never notified the residents or their representatives about changing the pharmacy. Staff also stated that they did not get notified beforehand, they were just told the facility is going to change the pharmacy.

Based on LPAs observations and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

**Civil Penalty Assessed during the visit**

Exit interview held. A copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 28-AS-20211028082256
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: 11/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/15/2021
Section Cited
CCR
87411(d)(4)
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87411Personnel Requirements-General(d)(d) All personnel shall be given on the job training or have related experience in the job assigned to them. (4)(4) Knowledge required to safely assist with prescribed medications which are self-administered. The requirement is not met as evidenced by
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The licensee has to ensure all personnel shall be given on the job training. The licensee will assign the job for the related experience staff. The licensee will come up a plan for the graveyard med-tech duty and send to LPA by POC dute date.
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LPA's interviews and recorded review, the caregivers did not receive any training and they were on the job duty of med-tech which posed a potential risk fo residents
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Type B
11/15/2021
Section Cited
CCR
87468.1(a)(16)
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87468.1 Personal Rights of Residents in All Facilities(a)(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (16)To receive or reject medical care or other services.
The requirement is not met by evidenced :
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The licensee will ensure the personal right of the residents. The facility will retrain the staff for the personal right and send the training log to LPA by POC due date.
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LPA interviewed six residents and four residents reported they did not get any notification before the facility changed the pharmacy which imposed a potiential risk of the residents
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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: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 28-AS-20211028082256
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: 11/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/02/2021
Section Cited
CCR
87355(e)
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87355 Criminal Record Clearance (e)(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
The requiremnt is not met as evidenced by:
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The licensee will ensure all individuals subjects to a criminal record shall prior to working, residing or volunteering in a licensesd facility. The licensee will come up a plan how to ensure resident safety for the coming two weeks and send to LPA by POC due date
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recorded review and LPA's observation: LPA observed there are two adults who have no criminal record cleareance reside in the facility (Rm#301) and they are not residents and they are friend of the owner which posed an immediate risk to residents (Civil Penalty Assess)
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Type B
11/15/2021
Section Cited
CCR
87208(a)
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87208 Plan of Operation (a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval.
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The licensee will ensure each facility shall have and maintian a current, written definitive plan of operation and any changes would affect the services of resident and submitted to Licensing. The licensee will send LPA a plan how to continue to maintain the current plan of correction in the future.
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The requirement is not met as evidenced by LPA interviews and record review: The owner of the facility admitted they were renting the residents' room to a friend which imposed a potiential risk of residents,
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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: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
10/28/2021 and conducted by Evaluator Christine Wong
COMPLAINT CONTROL NUMBER: 28-AS-20211028082256

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: 67DATE:
11/01/2021
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Virgilio AgasTIME COMPLETED:
02:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff removing daily medication from its originally received container
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Christine Wong conducted an unannounced complaint visit to investigate the above allegation. LPA met with receptionist- Giselle Provencio and explained the reason for the visit. A short time later, administrator, Virgilo Agas arrived.

The investigation consisted of the following: LPA interviewed six (6) residents, administrator and seven (7) staff. LPA also obtained the resdient roster, staff roster and medication training log. LPA also toured the facility.

The investigation revelaed of the following: Allegation "Staff removing daily medication from its originally received container" LPA interviewed residents and reported the staff did not remove the medication from the orginally received container. They have no issues with the medication. LPA interviewed the staff, staff reported recently they changed the pharmacy and all medications are in a pouch plastic bag instead of bubblepack. (See LIC 9099C for continuation)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 28-AS-20211028082256
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: 11/01/2021
NARRATIVE
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Staff stated that some residents had a hard time to tear off the pouch plastic bag. Therefore the staff put the medication into a paper cup which is easier for the resident to use it. Staff also stated that they never removed the medication to another container for more than 24 hours.

Based on the record review and interviews were conducted, 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 and appeal right was provided to administrator.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 6