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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603401
Report Date: 02/12/2024
Date Signed: 02/12/2024 09:31:07 PM


Document Has Been Signed on 02/12/2024 09:31 PM - It Cannot Be Edited

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 VILLAGEFACILITY NUMBER:
198603401
ADMINISTRATOR:VIRGILIO AGASFACILITY TYPE:
740
ADDRESS:607 WEST DUARTE RDTELEPHONE:
(626) 447-6070
CITY:ARCADIASTATE: CAZIP CODE:
91007
CAPACITY:200CENSUS: 83DATE:
02/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Virgilio Agas, administratorTIME COMPLETED:
05:30 PM
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Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met
with Virgilio (Gil) Agas, administrator, who assisted with visit. The facility is licensed to serve the elderly who are 60 years and older. It has 25 hospice wavier approved. Its capacity is 200 residents including 149 non-ambulatory, of which 15 may be bedridden. Rooms 101-119 are approved for bedridden. Annual fees are current.

During the visit, the Care tool was used, a facility tour was conducted, food supply was reviewed, medications/staff's files/residents' files were reviewed, and staff and residents were interviewed.

The facility is located in a residential neighborhood. It is three-story, 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. A physical tour was conducted. LPA toured Room# 224, 233, 202, and 111. 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 115.3 to 118.3 degrees Fahrenheit which was within Title 22 Regulation guidelines.

Facility had no pool. A water fountain (3 ft x 3 ft in size) located at the entrance outdoor was not operable and had no water. No firearms on the premises. Facility maintained a comfortable temperature for residents. Facility has a signal system and operates properly. Staff responded to the calls in less than one minute and came to the room in less than five minutes.
(- continued in LIC 809-C -)
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2024
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: 02/12/2024
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Sufficient supply of perishable and nonperishable foods was observed. Smoke detectors and carbon monoxide detectors were operable. They were not hard wired. Fire extinguishers had the last service on 12/11/23 and fully charged. Mandated documents and signages were posted in common areas. Medication were centrally stored in locked medication carts in the medication room and inaccessible to residents. Resident records were stored in a locked cabinet and inaccessible to residents.

No deficiencies were cited per California Code of Regulations. An exit interview was conducted. This report is discussed and provided to facility Administrator.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2024
LIC809 (FAS) - (06/04)
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