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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 03:47:14 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
12/23/2024 and conducted by Evaluator Bonnie Tao
COMPLAINT CONTROL NUMBER: 28-AS-20241223114623
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:
10:30 AM
MET WITH:Virgilio Agas, administrator
Justin Lee, administrator assistant.		TIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Facility has seven (7) employees do not have criminal clearance working at the premises.
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, reviewed staff records, and conducted a facility tour.

The investigation consisted of interviews with staff from staff#1 (S1) to staff#2 (S2), reviewed staff files from staff#3 (S3) to staff#10 (S10), 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: 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-20241223114623
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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In regard of the allegation the facility has seven (7) employees do not have criminal clearance working at the premises, it was alleged that seven uncleared staff were working at the facility. The investigation revealed the following: all two (2) staff interviewed were corroborate the allegation. Staff interviewed indicated two (2) staff who had been working at the facility were associated with the facility but not yet have fingerprint clearance. Per record review, S10 was no longer working at the facility for a while; however, S3 and S4 were associated with the facility but uncleared. Therefore, the 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 allegation is 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 Lee, administrator assistant. 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: 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-20241223114623
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
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 agreed to either obtain fingerprint clearance or let go staff#3 and staff#4 by 12/25/24.
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Per staff interviews and record review, staff#3 and staff#4 did not have criminal clearance prior to work at the facility. 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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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: 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