198603401-10-10-2023-28-AS-RORN-CWWQYV-20231024123544

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603401
Report Date: 10/10/2023
Date Signed: 10/10/2023 04:51:03 PM

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
10/03/2023 and conducted by Evaluator Bonnie Tao

COMPLAINT CONTROL NUMBER: 28-AS-20231003122019

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: 82	DATE:	10/10/2023
		UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	Virgilio Agas, administrator		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff refuses to assist residents.
Staff handles residents in a rough manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tao conducted an unannounced complaint investigation for the allegations listed above today. LPA met Administrator, Gil Agas and explained the purpose of today's complaint investigation visit.

Investigation consisted of the following:
LPA Tao obtained staff roster, resident roster and staff records; interviewed residents from resident#1 (R1), resident#3 (R3) to resident#6 (R6) and resident#8 (R8); attempted to interview resident #2 (R2) and resident #7 (R7); interviewed staff from staff#1 (S1) to staff #7 (S7), and conducted a facility tour.

Investigation revealed the following:
In regard of allegation, “staff refuses to assist residents,” it was alleged that staff #3 (S3) refuses to help residents. Per residents’ interviews, six (6) out of eight (8) residents corroborate the allegation.
(-continued in LIC9099C-)

Substantiated

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: 10/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

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-20231003122019

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: 10/10/2023

NARRATIVE

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Two (2) out of eight (8) residents were attempted but unable to be interviewed. It revealed that staff#3 had refused to assist residents. Per staff interviews, five (5) out of seven (7) staff corroborate the allegation. Two (2) out of seven (7) denied the allegation. It revealed staff #3 refuses to help residents. Per file review, facility only conducted one consultation meeting with S3 since S3 had refused to assist residents for multiple times on different residents. Thus, staff refused to assist residents in care.

In regard of allegation, “staff handles residents in a rough manner,” it was alleged that staff#3 (S3) is too rough with residents when assisting them. Per residents’ interviews, six (6) out of eight (8) residents corroborate the allegation. Two (2) out of eight (8) residents were attempted but unable to be interviewed. It revealed that staff#3 had being assisting residents in a rough manner. Per staff interviews, six (6) out of seven (7) staff corroborate the allegation. One (1) out of seven (7) denied the allegation. It revealed staff #3 handled residents with a rough manner. Thus, facility staff did not handle residents in a proper manner.

Based on LPA's observations and interviews conducted, the preponderance of evidence standard has been met. Therefore, the allegation is SUBSTANTIATED.

The following deficiency was cited per California Code of Regulations, Title 22. Refer to 9099D.

An exit interview was conducted with Administrator, Gil Agas and findings were discussed. A copy this report and appeal rights were provided to Administrator at time of visit.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20231003122019

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: 10/10/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed Type B 10/17/2023 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met by evidence of:	1 2 3 4 5 6 7	Licensee will review Title 22 Regulations, Section 87468.2 and submit a detailed written plan to ensure staff Rosario Bautista and facility staff are receiving the required in-service trainings / not refuse to assist residents according to the Regulation.
	8 9 10 11 12 13 14	Per staff/residents interviews conducted, staff Rosario Bautista refused to provide care to residents. Licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14	Licensee will provide a copy of names and signatures of all staff in attendance of trainings by POC due date. Licensee will submit a policy regarding staff’s refusal to assist residents by POC due date.
Deficiency Dismissed Type B 10/17/2023 Section Cited CCR 87468.1(a)(1)	1 2 3 4 5 6 7	To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met by evidence of:	1 2 3 4 5 6 7	Licensee will review Title 22 Regulations, Section 87468.1 and submit a detailed written plan to ensure staff Rosario Bautista and facility staff are receiving the required in-service trainings on providing care in a proper manner according to the Regulation.
	8 9 10 11 12 13 14	Per staff/residents interviews conducted, staff Rosario Bautista handled residents in a rough manner. Administrator did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14	Licensee will provide a copy of names and signatures of all staff in attendance of trainings by POC due date.

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: 10/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

LIC9099 (FAS) - (06/04)

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