198603401-3-13-2023-28-AS-FFIS-CQMM76-20230406092057

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603401
Report Date: 03/13/2023
Date Signed: 03/13/2023 03:50:14 PM

Unsubstantiated

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
03/07/2023 and conducted by Evaluator Bonnie Tao

COMPLAINT CONTROL NUMBER: 28-AS-20230307121336

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: 79	DATE:	03/13/2023
		UNANNOUNCED	TIME BEGAN:	09:07 AM
MET WITH:	Virgilio Agas, Administrator		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Facility staff did not provide a daily diet of the quantity necessary to meet the needs of the resident.

INVESTIGATION FINDINGS:

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

During the investigation visit was conducted, LPA Tao obtained staff roster, resident roster, resident#1’s (R1) records, interviewed residents from resident#1 (R1) to resident#5 (R5), interviewed staff from staff#1 (S1) to staff #5 (S5), and conducted a facility tour.

The investigation revealed the following:
In regard of allegation, “facility staff did not provide a daily diet of the quantity necessary to meet the needs of the resident,” it was alleged that resident#1(R1) did not get breakfast and lunch for two days in a row while the facility had COVID in Feb 2023. LPA interviewed residents, including four residents who was tested with COVID in Feb 2023. Five (5) out of five (5) residents stated staff did not fail to provide meals to residents.
(-continued in LIC 9099C-)

Unsubstantiated

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: 03/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2023

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-20230307121336

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: 03/13/2023

NARRATIVE

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Resident#1 interview revealed staff had delivered food trays of breakfast and lunch to resident’s room but deliveries were late for two days in a row. All staff interviewed denied the allegation. Thus, facility staff did not fail to provide proper daily diet to meet resident’s needs.

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 allegation 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 findings were discussed. A copy this report was provided to Administrator at time of visit.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2023

LIC9099 (FAS) - (06/04)

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