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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603401
Report Date: 05/11/2023
Date Signed: 05/11/2023 03:23:58 PM


Document Has Been Signed on 05/11/2023 03:23 PM - 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: 0DATE:
05/11/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Dr. Shin Kang, Licensee
Crystal Pak, Licensee		TIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Bonnie Tao and Licensing Program Manager (LPM) Fernando Fierros conducted an office meeting at the Monterey Park Adult & Senior Care office with Licensee Dr. Shin W. Kang, and Licensee Crystal Pak attended virtually via Face Time. The purpose of the office meeting is to discuss the ownership percentage of the facility with Licensee. Licensee is Goldwater SAG Holdings, LLC.

The following items were discussed during today’s meeting:
Ownership and percentage of owner for the limited liability corporation (LLC).
Licensee reported the LIC 309 dated 08/01/2020 which list Dr Shin W Kang as owning 91% and Crystal Pak as owning 9% of the Goldwater SAG Holdings, LLC was incorrect information provided to the department. The original LIC 309 dated June 03, 2020 did not reflect the correct managing members and percentages of ownership.

Managing Members Dr Shin W Kang and Crystal Pak informed the department of the following:
Licensee confirmed there have been no changes in the corporation since the effective date 02/24/21.
Licensee reported that Dr Shin W Kang owns 51% ownership and Crystal Pak owns 49 % of Goldwater SAG Holdings, LLC.

Licensee provided the following documents during the office meeting:
An updated LIC 309 Administrative Organization to reflect correct ownership percentages.

Licensing provided a copy of the following documents:
LIC 309 Administrative Organization dated 06/03/2020
LIC 309 Administrative Organization dated 08/01/2020
(-continued LIC 809C-)
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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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
VISIT DATE: 05/11/2023
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Licensee Dr. Kang stated facility had applied the decrease of facility capacity. Application of decrease of capacity is in the process.

Exit Interview conducted and a copy of this report was provided to Licensee Dr. Kang.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2023
LIC809 (FAS) - (06/04)
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