198603401-6-29-2023-28-AS-RORN-CX7L7E-20231102083015

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603401
Report Date: 06/29/2023
Date Signed: 06/29/2023 03:12:00 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
06/27/2023 and conducted by Evaluator Alberto Lopez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230627112030

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:	06/29/2023
		UNANNOUNCED	TIME BEGAN:	09:31 AM
MET WITH:	Virgilio Agas, Administrator		TIME COMPLETED:	03:21 PM

ALLEGATION(S):

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Facility is in disrepair

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced visit to this facility. LPA met with Administrator Virgilio Agas and LPA explained the purpose of the visit is to investigation the above allegation.

The investigation consisted of reviewing and obtaining staff and residents rosters, interviews with five staff (S#1–S#5), Eight residents (R#1-R#8 and a tour of random rooms and common areas. LPA was unable to interview maintenance worker.

Allegation: Facility is in disrepair. It is alleged that there is a small leak somewhere on the first floor and in R1 room under the bathroom sink.

(Continued on 9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023

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 4

Control Number 28-AS-20230627112030

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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: 06/29/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/13/2023 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 Maintenance and Operation (a) 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: n	1 2 3 4 5 6 7	Administrator will repair or replace facet in R1 room and repair or replace bathtub in R1 room by POC date and send proof to LPA.
	8 9 10 11 12 13 14	While inspecting R1 room. LPA observed the bathroom sink facet leaking and tub in R1 room in disrepair and exposing construction material under the finish on one side of the tub.	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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
06/27/2023 and conducted by Evaluator Alberto Lopez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230627112030

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:	06/29/2023
		UNANNOUNCED	TIME BEGAN:	09:31 AM
MET WITH:	Virgilio Agas, Administrator		TIME COMPLETED:	03:21 PM

ALLEGATION(S):

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Resident's room has mold.

INVESTIGATION FINDINGS:

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Allegation: Resident's room has mold.
The investigation revealed the following: It was alleged that there is black mold in R1 tub.
LPA interviewed Five staff and all five staff denied the allegations. During LPA Lopez tour of the physical plant on 6/29/2023, LPA did not observe any signs of black mold in R1 room, the common areas, bathrooms, or resident rooms. In interviews, Seven out of eight residents interviewed stated that they have never noticed black mold or heard of other residents complaining about black mold. R1 stated R1 does not know if the black appearance along side of R1 tub is mold. LPA inspected tub and the black appearance is part of the construction material that is exposed due to wear of the finish on the side of the tub.

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

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023

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

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 28-AS-20230627112030

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ARCADIA RETIREMENT VILLAGE	FACILITY NUMBER: 198603401
	VISIT DATE: 06/29/2023

NARRATIVE

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The investigation revealed the following: Administrator stated he is aware of the leak, and he reported it to maintenance man a long time ago. Administrator stated facility is old building and requires constant maintenance. Four of five staff stated they are aware of the leaks but are repaired promptly. R1 stated R1 sink facet leaks because it does not shut off properly. LPA checked 8 random rooms and only R1 room had facet that leaked. The drainpipe was inspected by LPA and staff while running sink water and LPA did not observe any water leaking under the sink. LPA inspected the tubs in all eight rooms and R1 room tub needs repair or replacement due to wear and tear on the one of the sides of the tub. There was no evidence of any leak on the first floor during visit.

NOTE: LPA observed other deficiencies during visit and addressed those on CM809 and 809D.

Based on LPA's observations, and interviews conducted the preponderance of evidence standard has been met, therefore the above allegations is found SUBSTANTIATED.

Deficiencies are being cited according to California Code of Regulations, Title 22, Division 6, Chapter 8 on LIC 9099D.

An exit interview was conducted with Administrator, A hard copy of this report and appeal right were provided.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 4