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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603401
Report Date: 10/20/2023
Date Signed: 10/20/2023 05:12:30 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
10/16/2023 and conducted by Evaluator Bonnie Tao
COMPLAINT CONTROL NUMBER: 28-AS-20231016123104
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: 82DATE:
10/20/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Virgilio Agas, administratorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff are not providing adequate food service to residents.
Staff did not ensure resident's room has a call button.
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) to resident#8 (R8); interviewed staff from staff#1 (S1) to staff #5 (S5) and conducted a facility tour.
Investigation revealed the following:

In regard of allegation, “staff are not providing adequate food service to residents,” it was alleged that residents’ meals had too much carb and not enough vegetable and fresh fruit.
(-continued in LIC9099C-)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023
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 5
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
10/16/2023 and conducted by Evaluator Bonnie Tao
COMPLAINT CONTROL NUMBER: 28-AS-20231016123104

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: 82DATE:
10/20/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Virgilio Agas, administratorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
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5
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7
8
9
Staff did not prevent resident's shower water from being uncomfortably hot.
INVESTIGATION FINDINGS:
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5
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7
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9
10
11
12
13
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: LPA Tao obtained staff roster, resident roster and staff records; interviewed residents from resident#1 (R1) to resident#8 (R8); interviewed staff from staff#1 (S1) to staff #5 (S5) and conducted a facility tour.

Investigation revealed that “staff did not prevent resident's shower water from being uncomfortably hot,” it was alleged that the shower hot water is too hot to resident. Per residents’ interviews, seven (7) out of eight (8) residents did not corroborate with the allegation. One (1) out of eight (8) residents corroborate with the allegation. It revealed that the hot water is not too hot to residents.
(-continued in LIC9099C-)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20231016123104
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: 10/20/2023
NARRATIVE
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Per staff interviews, five (5) out of five (5) staff denied the allegation. Per the water temperature tests conducted at the residents’ rooms, the water temperatures were in a range from 105 to 120 degree Fahrenheit which in compliance with Title 22 regulation. Thus, shower water temperature is not being too hot.

Although the allegation may have happened or are valid, there is not preponderance of evidence to prove the alleged violations did or did not occur, therefore, the allegation is UNSUBSTANTIATED.

An exit interview was conducted with Administrator, Gil Agas and a copy this report was provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20231016123104
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: 10/20/2023
NARRATIVE
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Per residents’ interviews, all eight (8) residents corroborate with the allegation. It revealed that residents’ meals did not have enough vegetable and fresh fruit. Per staff interviews, two (2) out of five (5) staff denied the allegation. Three (3) out of five (5) staff corroborate with the allegation. Per kitchen tour, food supplies on vegetable and fresh fruit were low. Thus, food services to residents were not adequate.

In regard of allegation, “staff did not ensure resident's room has a call button,” it was alleged that resident’s room did not have a working call button. Per residents’ interviews, seven (7) out of eight (8) residents did not corroborate with the allegation. One (1) out of eight (8) residents corroborate with the allegation. Per the facility tour, R1’s room did not have a working call button. Per staff interviews, five (5) out of five (5) staff denied the allegation. Therefore, resident’s room did not have a working call button.

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

Deficiencies were 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 FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20231016123104
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: 10/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/27/2023
Section Cited
CCR
87555(a)
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The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents.

This requirement was not met by evidence of:
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Licensee agreed to provide more vegetable and fresh fruit to residents’ meal by increasing vegetable and fruit supplies by POC due date.
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Per staff/residents interviews conducted, facility did not provide adequate food services to residents. Administrator did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
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Type B
10/26/2023
Section Cited
CCR
87303(a)
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The facility shall be clean, safe, sanitary and in good repair at all times.

This requirement was not met by evidence of:
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Licensee agreed to repair R1’s (room 242) call button by POC due.
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Per physical plant conducted, R1’s room did not have a working call button. Administrator did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
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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 FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5