198603401-2-3-2022-28-AS-BTAO-CBB2T6-20220203164012

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603401
Report Date: 02/03/2022
Date Signed: 02/03/2022 04:41:29 PM

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 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: 67	DATE:	02/03/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Agas Virgilio, Administrator		TIME COMPLETED:	05:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met with Agas Virgilio, administrator, who assisted with visit. The facility has a capacity of 200 residents which including 134 non-ambulatory and 15 bedridden. It is licensed to serve for the Elderly for 60 years and older. During the visit, the infection control domain tool was used, a tour of the facility was conducted, food supply was reviewed, and medications were reviewed. The facility is a stucco structure with 91 bedrooms, 91 bathrooms, 1 TV room, an administrative office, a restaurant style kitchen, a laundry room, a coin laundry room, a janitor storage room, an activity room, a dining room and two elevators. There is a covered patio area on the premises. The resident bedrooms are spacious and will easily accommodate the client's furnishings. Passageways, walkways, stairs and patios are free from obstructions. The entrance and side areas are free of hazards and debris. The facility was located in a residential neighborhood. Administrator certificate is current and the expiration date is 7/14/2023. A physical tour was conducted. LPA toured Room # 107, 108, 115, 119, 208, 210 and 220. Residents’ rooms were well furnished and in compliance. Bathrooms inspected were clean, operable, with the required grab bars and non-skid materials in the shower. Hot water temperature was in a range of 110. 3 to 115.5 degrees Fahrenheit which was within Title 22 Regulation guidelines. (- continued in LIC 809-C -)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2022

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: 02/03/2022

NARRATIVE

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Adequate linen and personal hygiene supplies was observed. Facility has no pool. Bodies of water was a fountain (3 ft x 3 ft in size) located in front of the entrance which is not in operation and inaccessible to residents. No firearms on the premises. Facility maintained a comfortable temperature for residents. Facility has a signal system and operates properly. LPA tested the signal system, staff came to the room in around 3 minutes.

Sufficient supply of perishable and nonperishable foods is observed. Knives, tools, sharp items are inaccessible to residents. Smoke detectors and carbon monoxide detectors are operable. they are not hard wired. Fire extinguishers’ last service is 2/16/21 and are fully charged.

The first aid kit is fully stocked. Mandated documents and signages are posted in common areas. The outdoor activity area has a shaded patio with ample seating. Medication are centrally stored in locked medication carts in the medication room and inaccessible to residents. Resident records are stored in a locked cabinet and inaccessible to residents. Toxic substances are inaccessible to residents. Outdoor facility space used for residents and leisure are completely enclosed by a fence with self-closing gates.

Deficiency was observed and cited per California Code of Regulations, Title 22 in LIC 809 D.

An exit interview was conducted. This report is discussed and provided to facility Administrator, whose signature on this form confirm receipt of these documents. A copy of appeal rights was provided

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2022

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(h)(6)

Incidental Medical and Dental Care (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year This requirement is not met as evidenced by: Upon reviewing medication and medication log for Residents #4 and #10, LPA observed the medication log was not logged since 1/2/22 to 1/3/22 while medication was administered. LPA did not see any documentation in regard to missing medication log. LPA was unable to determine medication log was updated accordingly.
	Deficient Practice Statement
1 2 3 4	Based on observation and medication record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/10/2022
	Plan of Correction
1 2 3 4	Administrator will ensure that all medication logs are updated as medication is administered effective immediately. Administrator will send LPA a copy of in-service training provided to the staff regarding Medication handling and a signed written statement stating Administrator has read section 87465, understands it and will abide by it.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2022

LIC809 (FAS) - (06/04)

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