198603401-8-31-2023-28-AS-RORN-CW2N5F-20230926100928

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603401
Report Date: 08/31/2023
Date Signed: 08/31/2023 11:34:35 AM

Substantiated

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
08/22/2023 and conducted by Evaluator Glenn Trueman

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230822142718

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: 87	DATE:	08/31/2023
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Virgilio Agas		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Licensee does not ensure facility is in good repair.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

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.
Resident R1's room was inspected at 10:10 AM.
Interview was conducted with Administrator at 9:45 AM.
Interview conducted with R 1 at 10:30 AM.
In regards to the allegation Licensee does not ensure facility is in good repair, based on interviews conducted and information gathered LPA upon inspection of R1's room observed the bathtub basin full of brown rust from the pipes and tissue paper.
LPA flushed the toilet and observed water coming out from the basin and more rust coming out in the bathtub.
Interview with Staff S 1 who stated that the bathroom issue in R 1's room has been going on for at least

Substantiated

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: 08/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 28-AS-20230822142718

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: 08/31/2023

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
26
27
28
29
30
31
32

3 to 5 days and maybe a week. Interview with Administrator who stated that he was made aware of clogging of R1's toilet by the resident and he went up there and declogged it and other staff bought fluid to apply to drain.
Stated 3 days later it was declogged.
Interview with R 1 who stated that she flushed toilet and there has been brown rust from pipes and tissue in bathtub and also water coming out at the basin after flushing.
Also said water leaked onto carpet and had to put towels on the floor in the restroom from the leaking.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the allegation is found to be substantiated. The deficiency is being cited on the attached LIC 9099D.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20230822142718

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/31/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/01/2023 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	MaIntenance and Operation The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Facility to repair R1's toilet immediately and submit by POC due date the date that a professional plumber will make the necessary repairs and submit receipt and contact information to Licensing.
	8 9 10 11 12 13 14	Based on inspection and interviews licensee failed to have the facility in good repair with R1's toilet not in good repair with brown rust from pipes filling bathtub after flushing which causes a potential Health and Safety Risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3