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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603401
Report Date: 11/19/2024
Date Signed: 11/19/2024 05:54:16 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
08/20/2024 and conducted by Evaluator Bonnie Tao
COMPLAINT CONTROL NUMBER: 28-AS-20240820113413
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: 82DATE:
11/19/2024
UNANNOUNCEDTIME BEGAN:
08:06 AM
MET WITH:Gil Agas, AdministratorTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Uncleared staff providing care to residents.
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 Administrator, Gil Agas and explained the purpose of today's visit.

On 08/20/24, LPA Tao conducted the initial investigation visit. On 11/05/24, LPA Tao conducted a subsequent visit. On 11/19/24, today, another subsequent visit was conducted. LPA obtained copies of staff and resident rosters, interviewed staff/residents, reviewed resident #1 (R1) and staff records, conducted a facility tour, and delivered findings.

The investigation consisted of interviews with staff from staff#1 (S1) to staff#3 (S3), residents from resident#1 (R1) to resident#6 (R6), reviewed staff#3 (S3) facility records, and conducted a physical plant.

(-continued on LIC 9099 C-)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Bonnie Tao
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024
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 4
Control Number 28-AS-20240820113413
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: 11/19/2024
NARRATIVE
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In regard of the allegation uncleared staff providing care to residents, it was alleged that an uncleared staff was working at the facility. The investigation revealed the following: All six (6) out of six (6) residents interviewed were corroborate the allegation. Resident interviews revealed that residents had seen that uncleared staff at the facility. Three (3) out of three (3) staff interviewed were corroborate the allegation. One of the interviewed staff was the alleged uncleared staff. Staff interviewed indicated staff had been working at the facility from months. Per record review, that uncleared staff was on payroll and received hourly pay from the licensee. Therefore, facility had uncleared staff providing care to residents.

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 Administrator, Gil Agas. A hard copy of the report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Bonnie Tao
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 28-AS-20240820113413
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: 11/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/20/2024
Section Cited
CCR
87411(g)(1)
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(g) Prior to employment or initial presence in the facility, all employees…(1) Obtain a California clearance or a criminal record exemption.

This requirement was not met by evidence of:
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Licensee had let go Staff#3 in Oct 2024. Staff was no longer working at the facilty.
POC was cleared.
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Per staff interviews and record review, Staff#3 did not have criminal clearance prior to work at the facility. Licensee did not comply with the section cited above which poses an immediatel 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.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Bonnie Tao
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4