198603401-9-12-2023-28-AS-RORN-CVTUVD-20230919155458

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603401
Report Date: 09/12/2023
Date Signed: 09/12/2023 05:47:29 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
07/14/2021 and conducted by Evaluator Bonnie Tao

COMPLAINT CONTROL NUMBER: 28-AS-20210714101240

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: 84	DATE:	09/12/2023
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Virgilio (Gil) Agas, administrator		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Facility has an infestation of bed bugs.
Staff failed to provide resident with clean linens
Staff failed to meet resident's needs.
Facility staff are not administering medication according to doctor's orders.

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.

On 07/23/21, LPA Tao conducted the initial investigation visit at the facility. LPA conducted staff/residents interviews, obtained staff/resident roster, obtained Resident #1’s (R1) files and related documents.

On 09/12/23, LPA Tao conducted a subsequent visit. During the visit, LPA obtained copies of staff and resident rosters, interviewed residents from resident #3 (R3) through resident #9 (R9), reviewed resident #1 (R1) records, obtained incident report, dated 2/4/21, conducted a facility tour and delivered findings.
Investigation consisted of the following: interviews of staff from Staff#1 (S1) to Staff#5 (S5); interviews of residents from Resident#1 (R1) through Resident#9 (R9); reviewed resident#1’s record reviews, reviewed medication, and conducted a facility tour. (-continued in LIC 9099 C-)

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: 09/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023

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-20210714101240

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: 09/12/2023

NARRATIVE

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In regard of the allegation, “facility has an infestation of bed bugs,” it was alleged that R1’s room had bed bugs. The investigation revealed the following: LPA interviewed resident#1(R1) and R1 stated there were bed bugs in R1’s room. Eight (8) out of nine (9) residents interviewed could not corroborate the allegation and did not see bed bugs at the facility. All five (5) staff interviewed denied the allegation. LPA toured R1’s room and did not observe any bed bugs or trace of bed bugs. Per file review, facility was in contract with pest control company to take preventive action to prevent pest issue. Pest control company serviced the facility monthly and did not report bed bugs issues. Thus, facility did not have bed bugs infestation.

In regard of the allegation, “staff failed to provide resident with clean linens,” it was alleged that staff did not provide clean linens to residents. The investigation revealed the following: One (1) out of nine (9) residents interviewed state facility did not provide clean linen and no regular laundry service provided at the facility. Eight (8) out of nine (9) residents interviewed could not corroborate the allegation and stated facility had provided laundry services daily or at least every other day, including providing clean linen, bed sheets, and clean clothes. All five (5) staff interviewed denied the allegation. Staff interview revealed facility had a regular schedule on laundry services provided to all residents. Therefore, facility provided resident with clean linens and laundry services.

In regard of the allegation, “staff failed to meet resident's needs,” it was alleged that facility did not have hot water. The investigation revealed the following: One (1) out of nine (9) residents interviewed state facility did not have hot water. Eight (8) out of nine (9) residents interviewed stated facility had hot water. All five (5) staff interviewed denied the allegation. LPA randomly selected some resident’s rooms to test for hot water. All rooms had hot water from the shower and sinks. Therefore, facility provided hot water to meet resident’s needs.

In regard of the allegation, “facility staff are not administering medication according to doctor's orders,” it was alleged that facility staff withhold resident’s medication and did not follow physician’s prescription to administer resident’s medication. The investigation revealed the following: One (1) out of nine (9) residents interviewed state facility did not administer medication as prescribed. Eight (8) out of nine (9) residents interviewed could not corroborate the allegation and stated staff had followed doctor’s prescription to give medication to residents. All five (5) staff interviewed denied the allegation. Per medication record review, LPA reviewed residents’ medication records of R4, R5, and R6. (-continued in LIC 9099 C-)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210714101240

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: 09/12/2023

NARRATIVE

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Medication records matched with prescription and medication administered. Therefore, facility staff administered medication as prescribed.
Although the allegations 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.

No deficiencies are being cited according to California Code of Regulations, Title 22, Division 6, Chapter 8.

An exit interview was conducted with Administrator, Gil Agas. A hard copy of this report was provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023

LIC9099 (FAS) - (06/04)

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