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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603401
Report Date: 10/22/2024
Date Signed: 10/22/2024 04:06:46 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
10/17/2024 and conducted by Evaluator Noemi Galarza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20241017120729
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:
10/22/2024
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Virgilio Agas, AdministratorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff did not ensure the hot water is at a safe temperature.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Galarza conducted an initial 10-day complaint investigation visit regarding the above allegations. LPA discussed the purpose of the visit with Administrator Virgilio Agas.

The investigation consisted of: A physical plant tour of the interior common areas, kitchen and resident rooms was completed. LPA randomly selected rooms and tested the hot water temperature in a total of 16 resident rooms, as well as kitchen faucets. Residents (R1-R12) and staff (S1-S8) were interviewed. A copy of R1's Admission Agreement, Client/Resident Personal Property and Valuables, Register of Facility Residents, and LIC 500 Personnel Report were obtained.

*Narrative continues next page.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2024
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 5
Control Number 28-AS-20241017120729
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: 10/22/2024
NARRATIVE
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Allegation: Staff did not ensure the hot water is at a safe temperature. It was reported that the hot water temperature in resident room faucets is"scalding" hot. A total of 12 residents were interviewed, of which all reported that earlier in the month the facility was without hot water for close to 2 weeks. Residents stated the water heater problem has been fixed, and now they have hot water. According to staff interviews, between October 4, 2024- October 14, 2024, the entire building did not have hot water because the boiler controller was faulty and the sensors were malfunctioning. Administration staff provided a copy of the work order invoice. A total of 8 staff were interviewed. All the staff denied the allegation. However, Administration, caregiver, and housekeeping staff witnessed during the inspection that the hot water in resident rooms was not within Title 22 regulation of "not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C)." LPA randomly tested the hot water of 16 faucets. Ten (10) out of the 16 faucets measured above 120 DF. The hot water temperature ranged between [125 DF - 143.1 DF]. Therefore, there is sufficient evidence to corroborate the allegation.

Based on observation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency is being cited according to Title 22. See LIC 9099D.


An exit interview was conducted with Administrator Virgilio Agas. A copy of the report and appeal rights were issued.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20241017120729
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: 10/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/23/2024
Section Cited
CCR
87303(e)(2)
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Maintenance and Operation. Water supplies and plumbing fixtures shall be maintained as follows: Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water
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Manager adjusted the boiler temperature during the visit, and agreed to submit a temperature log showing all shifts tested the hot water temperature in resident rooms. If there continues to be temperature reading inconsistencies, a technician shall be contacted.
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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).
Based on observation, the hot water temperature readings today measured between 125 DF - 143.1 DF; which poses an immediate health and safety 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.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
10/17/2024 and conducted by Evaluator Noemi Galarza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20241017120729

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: DATE:
10/22/2024
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Virgilio Agas, AdministratorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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9
Staff gave resident's personal item to another resident in care.
INVESTIGATION FINDINGS:
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13
Licensing Program Analyst (LPA) Galarza conducted an initial 10-day complaint investigation visit regarding the above allegations. LPA discussed the purpose of the visit with Administrator Virgilio Agas.

The investigation consisted of: A physical plant tour of the interior common areas, kitchen and resident rooms was completed. LPA randomly selected rooms and tested the hot water temperature in a total of 16 resident rooms, as well as kitchen faucets. Residents (R1-R12) and staff (S1-S8) were interviewed. A copy of R1's Admission Agreement, Client/Resident Personal Property and Valuables, Register of Facility Residents, and LIC 500 Personnel Report were obtained.

*Narrative continues next page.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20241017120729
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: 10/22/2024
NARRATIVE
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Allegation: Staff gave resident's personal item to another resident in care. It is alleged that approximately one (1) week ago staff [name unknown] gave away resident (R1's) power wheelchair to another resident because staff "knew it was going to be junked". A total of 8 staff were interviewed, of which all denied the allegation, and stated that resident's personal belongings are not removed from resident rooms without resident consent. Staff stated that R1 has 2 power wheelchairs, and has had the older inoperable wheelchair in the room for over 1 year. Housekeeping and caregiver staff stated power wheelchairs are very heavy and if inoperable are hard to move. One (1) out of 12 residents confirmed the allegation. No other residents reported problems with personal items being removed by staff. LPA reviewed R1's file and observed that the resident declined to have their personal items inventoried upon admission, and the Client/Resident Personal Property and Valuables (LIC 621) form was waived and signed by the resident upon admission date. Therefore, there is insufficient evidence to support the 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.

An exit interview was conducted and a copy of this report was discussed and provided to facility Administrator Virgilio Agas.



NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5