198603401-3-2-2022-28-AS-BTAO-CC64TA-20220302182248

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603401
Report Date: 03/02/2022
Date Signed: 03/02/2022 06:22:52 PM

Document Has Been Signed on 03/02/2022 06:22 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 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: 67	DATE:	03/02/2022
TYPE OF VISIT:	Office	UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Licensee, Shin Kang, and Administrator, Agas Virgilio		TIME COMPLETED:	05:00 PM

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	An informal conference was held virtually via Microsoft Team on 3/2/2022. The purpose of this informal meeting was to discuss the following issues and/or concerns: Physical Plant repairs, Lines of communication between licensee and administrator, Non-receipt of W-2’s by employees, Dementia Care Plan, Transportation of residents to and from medical appointments, rodents in the facility and number of complaints made regarding the facility since the license effective date on 2/24/21. The attendees present in this virtual meeting were Licensing Program Analyst (LPA) Bonnie Tao, Licensing Program Manager (LPM) Fernando Fierros, Licensee, Shin Kang, and Administrator, Agas Virgilio. The following items were discussed during today informal conference and licensee agreed to the following: Licensee agreed to ensure that communication between the Administrator and licensee will be on a as needed basis and licensee will respond to administrator request for repair on the same day. Licensee agreed that the administrator will has authority to make repairs under a cost of $500, Licensee informed Administrator to proceed fixing them. For physical plant issues above a cost of $500, Licensee said administrator to call Licensee and follow up with an email. Licensee will respond to administrator on the same day. Licensees agrees to make repairs to the physical plant as needed to keep the facility in compliance with Title 22 regs. Licensee agrees to have resident#1 reassessed by 03/04/22 regarding the Dementia diagnoses and if resident is diagnosed with Dementia, licensee will assist in finding resident appropriate placement. Licensee does not wish to pursue obtaining a Dementia Care Plan with the Department. Regarding Dementia Plan, Administrator stated the facility did not have an approval Dementia Plan and did not intend to obtain one from Licensing. For the residents who have dementia, Administrator will have physicians to re-access the residents and follow eviction notice process for an appropriate placement if applicable. (-continued in LIC 809 C -)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022

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: 03/02/2022

NARRATIVE

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Licensee agrees to notify the department per Title 22 regs, if rodents are reported in the facility and is aware that it is the licensee’s responsibility to cross report rodents in the facility to the Los Angeles County Public Health “Environmental Health”.

Regarding W-2s for January and February of 2021, Licensee stated that the licensee does not have authority to re-activate the account for Jan-Feb 2021 to process W-2, as the account was in the name of the former licensee.

Regarding transportation arrangement for residents, administrator said the licensee will ensure resident are provided with transportation to and from medical appointment and is utilizing the transportation company "Access".

Licensee will advise the department by 03/04/22 as to whether the licensee will update the plan of operation in regard to the use of the facility transportation van.

The following Section of Title 22 were discussed with Licensee and a copy given via email:
- 87208: Plan of Operation
- 87211: Reporting Requirements
- 87303: Maintenance and Operation
- 87464: Basic Services
- 87507: Admission Agreements
- 87705: Care of Persons with Dementia

LPA requested the following items to be provided by 03/04/22:
- Signed document from Licensee giving Administrator authorization to repair the physical plant as needed.
- Unusual Incident Report (LIC 624) regarding cross reporting rodent issue to LA County Public Health
- Copy of the staff payroll (Jan 2022 through Feb 2022)
- Copy of all utility bills for January/February 2022.
- Copy of facility rent payment for February/March 2022.

No deficiencies were issued during today's virtual meeting. Exit interview was conducted with Licensee and a copy of this report was emailed to Administrator for signature.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022

LIC809 (FAS) - (06/04)

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