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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603401
Report Date: 09/19/2024
Date Signed: 09/19/2024 02:24:03 PM

Unsubstantiated


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
09/16/2024 and conducted by Evaluator Tena Herrera
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240916151446
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: 88DATE:
09/19/2024
UNANNOUNCEDTIME BEGAN:
09:44 AM
MET WITH:Gil Agas - Administrator TIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Facility staff served a contaminated beverage to resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced complaint investigation for the allegations listed above. LPA met Administrator, Gil Agas and explained the purpose of today's complaint investigation visit.

The investigation consisted of the following:
LPA obtained staff roster, resident roster, toured kitchen, conducted 4 Staff interviews and 9 Resident interviews.

(Continued on LIC9099-C)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Tena Herrera
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024
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 2
Control Number 28-AS-20240916151446
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: 09/19/2024
NARRATIVE
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The investigation revealed the following:
Allegation: Facility staff served a contaminated beverage to resident.
It is alleged that Staff #1 (S1) purposely contaminated Resident #1's (R1's) coffee, when during lunch on 9/12/2024. LPA interviewed S1 and S1 denied the above allegation and stated that R1 did question the taste of the coffee on 9/12/24 but left the dining shortly after. S1 further stated they have never contaminated any residents food or drinks and is something they would never do. LPA interviewed additional 3 Staff and all staff interviewed denied the above allegation and stated they have never seen a staff member contaminate a residents food or drink. LPA interviewed 9 Residents and 8 out of 9 Residents denied the above allegation and stated they have never observed their food or drinks to be contaminated and have never suspected staff of doing such things. LPA toured kitchen and observed coffee machine and it appeared to be clean and sanitary, staff interviewed also confirmed that the machine is serviced monthly and cleaned out daily after each shift.

Based on statements and interviews conducted with staff and residents, and tour of kitchen, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview held, and a copy of this report was provided to Gil Agas.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Tena Herrera
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024
LIC9099 (FAS) - (06/04)
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