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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603401
Report Date: 03/03/2023
Date Signed: 03/03/2023 05:51:32 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
02/21/2023 and conducted by Evaluator Bonnie Tao
COMPLAINT CONTROL NUMBER: 28-AS-20230221140950
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: 79DATE:
03/03/2023
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Gil Agas, AdministratorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff is refusing to assist residents.
Staff are not meeting residents needs in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tao conducted a subsequent unannounced complaint investigation for the allegations listed above today. LPA met Administrator, Gil Agas and explained the purpose of today's visit.

The initial visit was conducted on 02/27/23. The investigation consisted of interview of staff#1 (S1); interviews of residents from resident#4 (R4) to resident#6 (R6); obtain of resident roster and staff roster; and tour of the facility. Today, the investigation consisted of interviews of staff from staff#2(S2) to staff#7 (S7); interviews of residents from resident#1 (R1) to resident#3 (R3) and Resident #7 (R7); obtain of resident roster and staff roster; and tour of the facility.

In regard of allegation, “staff is refusing to assist residents,” it was alleged that staff was refusing to assist residents for care and assistance.

(- continued in LIC 812C-)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023
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 5
Control Number 28-AS-20230221140950
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: 03/03/2023
NARRATIVE
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LPA interviewed residents, four (4) out of seven (7) residents stated facility staff and staff#3 (S3) refused to assist residents to provide care. Three (3) out of seven (7) residents could not corroborate the allegation. Five (5) out of seven (7) staff interviewed stated staff had refused to help residents for care. Two (2) out of seven (7) staff denied the allegation. Thus, facility staff had refused to assist residents.

In regard of allegation, “staffs are not meeting residents needs in a timely manner,” it was alleged that residents have to wait a long for getting staff's help. LPA interviewed residents, seven (7) out of seven (7) residents stated they would usually wait for 15 - 30 minutes for staff assistance after called for help. Five (5) out of seven (7) staff interviewed stated staff may not attend and help residents timely. Two (2) out of seven (7) staff denied the allegation. During the visit, LPA conducted tests by calling the facility intercom and timed the staff's arrival time to residents' room. It took 20 minutes for staff to arrive to residents’ room. Therefore, there was preponderance of evidence to show facility staff did not assist residents timely.

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 and Assisted administrator, Justin Lee. A hard copy of this report and appeal right were provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20230221140950
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: 03/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/10/2023
Section Cited
CCR
87468.2(a)(4)
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(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
This requirement was not met by evidence of:
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Licensee will review Title 22 Regulations, Section 87468.2 and submit a written plan detailing how he will ensure that staff are receiving the required in-service trainings according to the Regulation. Licensee will submit a staffing plan to ensure sufficent staff to provide care to residents timely.
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Per interviews conducted, staff refused to provide care to residents and care was not provided in a timely manner. Based on interviews and observation, the Administrator did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
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Licensee will provide a copy of names and signatures of all staff in attendance of trainings by POC due.
CCR
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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: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
02/21/2023 and conducted by Evaluator Bonnie Tao
COMPLAINT CONTROL NUMBER: 28-AS-20230221140950

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: 79DATE:
03/03/2023
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Gil Agas, AdministratorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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2
3
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5
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7
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9
Staff failed to treat residents with respect and dignity.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tao conducted a subsequent unannounced complaint investigation for the allegations listed above today. LPA met Administrator, Gil Agas and explained the purpose of today's visit.

The initial visit was conducted on 02/27/23. The investigation consisted of interview of staff#1 (S1); interviews of residents from resident#4 (R4) to resident#6 (R6); obtain of resident roster and staff roster; and tour of the facility. Today, the investigation consisted of interviews of staff from staff#2(S2) to staff#7 (S7); interviews of residents from resident#1 (R1) to resident#3 (R3) and Resident #7 (R7); obtain of resident roster and staff roster; and tour of the facility.

In regard of allegation, “staff failed to treat residents with respect and dignity,” it was alleged that staff handled residents in a rough manner and made inappropriate comments towards resident. LPA interviewed residents, one (1) out of seven (7) residents stated facility staff made inappropriate comment towards resident. Staff had apologized to resident and resident accepted the staff apologies. (-Continued in LIC 812C-)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20230221140950
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: 03/03/2023
NARRATIVE
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Five (5) out of seven (7) staff interviewed stated there was a single incident that a staff made inappropriate comment towards resident and staff had apologized to resident. Administrator had discussed with that staff and stated staff would not to do it again. All residents interviewed stated staff did not handle residents roughly. Two (2) out of seven (7) denied the allegation. Per file review, administrator had a self – reported incident report to Licensing stated that incident which staff made a negative comment toward resident and staff had apologized to resident. That incident was settled. Thus, there was not preponderance of evidence to show facility staff fail to treat residents with respect and dignity.

Based on the information obtained during the investigation, interviews with staff, residents, review of resident files and LPA's observation, the investigation did not reveal any evidence to support the allegations mentioned above.

Although the allegations may have happened or are valid, there is not preponderance of evidence to prove the alleged violations did or did not occur, therefore, the allegation is UNSUBSTANTIATED.

An exit interview was conducted with Administrator, Gil Agas and assisted administrator, Justin Lee. Finding was discussed. A copy this report was provided to Administrator at time of visit.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5