198603401-3-2-2022-28-AS-LHIS-CD6HM4-20220404061829

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603401
Report Date: 03/02/2022
Date Signed: 03/02/2022 01:17:56 PM

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
02/25/2022 and conducted by Evaluator Cynthia D Chan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220225135405

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: 69	DATE:	03/02/2022
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Virgilio Agas, Administrator		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Facility heater is in disrepair.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Cynthia Chan conducted an unannounced complaint investigation for the allegation – facility heater is in disrepair. LPA met with Virgilio Agas, the Administrator and stated the purpose of the visit.

LPA Chan obtained a copy of the staff roster and resident roster. LPA toured the facility and inspected rooms #114, #115, #201, #211, #221, #246, #331, and #328. Interviews were conducted with the Administrator, 4 Staff, and 8 residents.

Regarding allegation – Facility heater is in disrepair. During the visit today, LPA toured 8 resident rooms and tested the heater in the rooms. Each room has a thermostat where residents can adjust the temperature accordingly. The heater for rooms #115, #201, #211, #221, #246, and #328 were not working properly during the inspection. These rooms did not heat up after a few minutes nor were there warm air coming out from the vents.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022

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-20220225135405

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: 03/02/2022

NARRATIVE

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The Administrator was aware that some of the rooms’ heater did not working properly, therefore in the interim, portable heaters were provided in those rooms to ensure residents’ comfort. 3 out of 4 Staff acknowledged the heater in some of the residents’ rooms were not working and residents were given portable heaters to use. LPA interviewed 8 residents and 4 indicated the heater does not work and currently using a portable heater. The other 4 residents stated the room heaters are working fine and kept warm, even though LPA observed portable heaters in some of those rooms. Based on information gathered, there was no maintenance order issued for the heaters to ensure the rooms are in good repair.

Based on LPA observations and interviews conducted, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 8), is being cited on the attached LIC 9099D.

An exit interview was conducted. The Plan of Correction was reviewed and developed with Administrator. A copy of this report and appeal rights were provided.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20220225135405

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: 03/02/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/16/2022 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The licensee shall test the residents rooms to ensure the heaters are working properly. The licensee shall provide proof that the heaters for rooms #115, #201, #211, #221, #246, and #328 work adequately to provide heat by POC due date 3/16/22.
	8 9 10 11 12 13 14	Based on observation and interviews, the licensee did not ensure the heater in rooms #115, #201, #211, #221, #246, and #328 are in good repair which poses a potential health, safety, and personal rights risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022

LIC9099 (FAS) - (06/04)

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