198603401-3-27-2023-28-AS-RORN-CQSLDA-20230411083935

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603401
Report Date: 03/27/2023
Date Signed: 03/27/2023 03:00:31 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
03/22/2023 and conducted by Evaluator Glenn Trueman

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230322160241

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:	03/27/2023
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Virgilio Agas		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Staff member is intervening with resident's ability to communicate directly with their physician.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Glenn Trueman conducted a complaint investigation at the facility. Upon arrival, LPA met with Administrator Virgilio Agas and explained the purpose of the visit.
The purpose of the visit is to investigate the allegation listed above.
During today's visit, LPA obtained a copy of the Staff/Resident Roster. Special Incident Report's (SIR's) were submitted.
File of Resident R 1 was reviewed and Identification and Emergency Information, Physician's Peport and Assisted Living Waiver (ALW) Program and Individual Service Plan (ISP) were submitted.
At today's visit interviews were conducted with Administrator and Social Worker from Assisted Living Waiver (ALW) Program from 12:40 P. M. to 1:30 P.M.
Interview was conducted telephonically with Staff S 1 from 1:35 P.M. to 1:55 P.M.
Interview was conducted with Resident R 1 from 2:00 P.M. to 2:25 P.M.
In regards to the allegation Staff member is intervening with resident's ability to communicate directly with their physician, based on interviews conducted and information gathered the Social Worker from ALW

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023

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-20230322160241

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: 03/27/2023

NARRATIVE

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Program stated that she is aware of Resident R 1 having psychotic issues. Stated that R 1 had an
appointment scheduled with the Primary Care Provider made by the facility in order to get doctor's authorization to refill medication, but R 1 declined after the appointment was made.
Said she knows facility will talk to doctor and doctor will re-fill. Said facility is just the middle man to request certain medications and doctor will be the one to authorize it..
Interview with Med-Tech who stated she only called for appointment with office staff member at the doctor's office and did not directly speak with the doctor. Stated that R1 had stated her phone was blocked and asked her to give the doctor a call
Administrator stated he has worked with ALW Social worker regarding R 1 and psychotic issues and has issued SIR's regarding hallucinations and other psychotic behaviors.
Stated that appointment was made to refill medication with R 1's doctor, but she cancelled.
Interview with R 1 who confirmed that she had told med-tech her phone was blocked and asked med-tech to call her doctor to schedule an appointment.
Stated that she didn't follow thru on scheduled appointment and that med-tech is being paid by outsiders to give her a hard time psychiatrically.
Review of Physician's Order dated 02/24/2023 shows Depakote as a listed medication.
Interview was conducted telephonically at 2:30 P. M. with representative for the Primary Care Provider who stated that the doctor does not speak telephonically with the facility to make changes to a resident's medication. Stated that a scheduled appointment is needed in order for any medication adjustments.

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, Virgilio Agas and findings were discussed.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023

LIC9099 (FAS) - (06/04)

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