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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603401
Report Date: 12/24/2024
Date Signed: 12/24/2024 03:48:51 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
12/20/2024 and conducted by Evaluator Bonnie Tao
COMPLAINT CONTROL NUMBER: 28-AS-20241220164541
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: 76DATE:
12/24/2024
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Virgilio Agas, administrator, and
Justin Lee, administrator assistant		TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Resident’s carpet and flooring are in disrepair affecting resident’s mobility.
Staff do not ensure that resident has hot water.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tao conducted a subsequent unannounced complaint investigation for the allegation listed above today. LPA met Gil Agas, Administrator and Justin Lee, administrator assistant. The purpose of today's visit was explained.

On 12/23/24, LPA Tao conducted the initial investigation visit. On 12/24/24, today, LPA Tao conducted a subsequent visit. LPA obtained copies of staff and resident rosters, interviewed staff, and conducted a facility tour.

The investigation consisted of interviews with staff from staff#1 (S1) to staff#2 (S2), interviewed residents from resident#1 (R1) to resident#3 (R3) and conducted a physical plant to R1’s and R2’s rooms.

(-continued on LIC 9099 C-)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:

DATE: 12/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/24/2024
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-20241220164541
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: 12/24/2024
NARRATIVE
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The investigation revealed the following:

In regard the allegation of staff do not ensure that resident has hot water, it was alleged that hot water was not delivered to residents’ bathrooms for showers on a regular basis. LPA interviewed resident#1, interview revealed hot water was delivered to resident’s bathroom but the temperature was above 120 degree F. Staff interviews revealed that a new water boiler was installed and the thermostat was set to a range from 115 degree F to 120 degree F. LPA toured the facility and tested the water temperature in residents’ rooms. The water was measured from 123.8 degree F to 125 degree F. Thus, staff failed to ensure the hot water that delivered to residents for showers was in compliance with Title 22 regulation which the temperature should be between 105 degree F to 120 degree F.

In regard the allegation of resident’s carpet and flooring are in disrepair affecting resident’s mobility, it was alleged that the carpet in resident’s room had mold and the flooring in resident’s bathroom was disrepair. LPA interviewed resident#1, the resident interview revealed the room carpet was saturated with moisture and started to black stains/spots. LPA conducted a physical plant and observed the resident’s room had stain spots on the carpet and the resident’s bathroom had broken vinyl flooring at the entrance area. Staff interviews were corroborated to the allegation. Thus, resident’s carpet and flooring were in disrepair.

Based on review of documents and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22, Division 6, Chapter 1. See LIC 9099D.



An exit interview was conducted with Justin, administrator assistant. A hard copy of the report and appeal rights were provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:

DATE: 12/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/24/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 28-AS-20241220164541
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: 12/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/25/2024
Section Cited
CCR
87303(e)(2)
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(2) … hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C)

This requirement was not met by evidence of:
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Licensee agreed to adjust the hot water temperature in a range of 105 -120 degree F by the POC due date.
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Based on interviews and observation, the hot water delivered to residents’ rooms was above 120 degree F. Licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
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Type B
01/10/2025
Section Cited
CCR
87303(a)
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The facility shall be clean, safe, sanitary and in good repair at all times.

The requirement is not met by evidence of:
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Licensee agreed to repair the bathroom floor and clean the carpet by POC due date. Licensee will provide the proof of repair to Licensing.
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R1’s room had stain spots on the carpet and broken vinyl flooring in the bathroom. Based on interviews and observation, the 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.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:

DATE: 12/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/24/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4