198603401-11-15-2024-28-AS-RORN-DB8NS2-20241121094223

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603401
Report Date: 11/15/2024
Date Signed: 11/15/2024 02:30:54 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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
09/23/2024 and conducted by Evaluator Daniel Konishi

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240923085819

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: 82	DATE:	11/15/2024
		UNANNOUNCED	TIME BEGAN:	08:55 AM
MET WITH:	Gil Agas, Administrator		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Staff did not dispense medications as prescribed.
Staff neglect resulted in resident falling.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Daniel Konishi conducted a subsequent unannounced complaint investigation for the allegations listed above today. LPA met Administrator, Gil Agas and explained the purpose of today's visit.

On 09/27/24, the initial investigation visit was conducted. The investigation consisted of the following:
LPA interviewed the Administrator at 11:55 am. LPA also reviewed and requested copies of Resident #1 (R1) file documents such as Medication Administration Records for (July 2024, August 2024, September 2024), Medication Physician’s Orders, Physician’s Report, Preplacement Appraisal Information Sheet, Functional Capability Assessment, ID Emergency Contact Sheet, Incident Reports pertaining to R1, and Staff and Resident Roster. LPA also interviewed R1 to Resident # 9 (R9) and Staff #1 (S1) to Staff #5 (S5). LPA also reviewed a random sample of medications and all medications are given as prescribed.

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20240923085819

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ARCADIA RETIREMENT VILLAGE	FACILITY NUMBER: 198603401
	VISIT DATE: 11/15/2024

NARRATIVE

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During today's visit, LPA obtained the following documents: R1’s Physician’s Orders, Doctor’s Prescription Request, and Medication Administration Records (September 2024, October 2024, November 2024). LPA did not observe any health and safety concerns. LPA interviewed R1, Witness #1 (W1) and the Administrator.

Allegation: Staff did not dispense medications as prescribed. It is alleged that the facility staff are not providing medications correctly which has caused R1 to be taken to the hospital frequently. No other details are provided. During initial visit, LPA reviewed a random sample of medications of five (5) residents and all medications are given as prescribed. During the initial visit, LPA interviewed six (6) out of six (6) staff and they all denied the allegation. During the initial visit, LPA interviewed nine (9) out of nine (9) residents and they all claim to receive all medication as prescribed from the staff. During today's visit, LPA reviewed R1's medications, Doctor’s Prescription Request, and Medication Administration Record (September, October, November 2024), all medications are given as prescribed. LPA also interviewed R1 and R1 stated that medications are received to R1 as prescribed. There is not enough evidence to substantiate.

Allegation: Staff neglect resulted in resident falling. It is alleged that the staff have continued to provide R1 with the incorrect medication resulting in R1 falling and being incoherent. No other details are provided. During the initial visit, LPA interviewed six (6) out of six (6) staff and they all denied the allegations and nine (9) of nine (9) residents all said they have not experienced nor witnessed any falls due to staff neglect. During today's visit, based on interview, R1 stated that R1 fell due to "dazing off" and did not allege the falls were due to staff neglect. R1 stated that the physician believe it may be due to one medication so R1's physician discontinued the one medication in September 2024. During R1's three years of residence, R1 has only experienced falling three times. LPA reviewed Special Incident Reports of R1's the three falls which occurred once in August 2024 and twice September 2024. For all three falls, R1 was taken to the hospital suffered no fractures and was treated for minor injuries. No falls from R1 have been reported ever since the fall in September 2024. There is not enough evidence to substantiate.

Based on statements and interviews conducted with staff, clients, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations 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 allegations are UNSUBSTANTIATED.

Exit interview held with the Administrator, Gill Agas and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

LIC9099 (FAS) - (06/04)

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