198603401-1-21-2025-28-AS-FFIS-DDKU5J-20250204141645

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603401
Report Date: 01/21/2025
Date Signed: 01/21/2025 04:55:02 PM

Unsubstantiated

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
12/20/2024 and conducted by Evaluator Bonnie Tao

COMPLAINT CONTROL NUMBER: 28-AS-20241220164541

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: 74	DATE:	01/21/2025
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Gil Agas, administrator Justin Lee, administrator assistant		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Resident’s room is malodorous due to moldy carpet.
Staff are not maintaining a healthy environment for resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tao conducted a subsequent complaint investigation visit for the allegations listed above today. LPA met with Gil Agas, administrator and Justin Lee, administrator assistant. The purpose of today's visit was explained.

The initial visit was conducted on 12/24/24. This subsequent investigation visit consisted of interviews with staff from staff#1 (S1) to staff#2 (S2), interviewed residents from resident#1 (R1) to resident#7 (R7) and conducted a physical plant to resident rooms from R1 to R5.

The investigation revealed the following:
In regard the allegation of resident’s room is malodorous due to moldy carpet, it was alleged that resident’s room had black stains on the carpet. Per resident interviews, six (6) out of seven (7) residents interviewed could not corroborate the allegation. One (1) out of seven (7) residents interviewed stated there were black stains on the room carpet and described those stains as mold spots. (-continued on LIC 9099 C-)

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Bonnie Tao
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025

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-20241220164541

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: 01/21/2025

NARRATIVE

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Per the interview of resident#1 (R1), resident stated those black stains were mold spots. Per staff interviews, all staff denied the allegation. Staff could not determine the black stains on the carpet were mold spots. Administrator had hired a carpet cleaning professional to shampoo and deep clean the carpet. Staff had taken immediate action to clean the carpet when aware of the issue. Per LPA’s observation during the physical plant, the black spots were shampooed and cleared. Thus, the residents’ rooms did not observe to have moldy carpet.

In regard the allegation of staff are not maintaining a healthy environment for resident, it was alleged that resident’s room had mold which was not healthy to resident. Per resident interviews, six (6) out of seven (7) residents interviewed could not corroborate the allegation. One (1) out of seven (7) residents interviewed stated there were black stains on the room carpet and described those stains as mold. Per the interview of resident#1 (R1), resident stated those molds on the carpet made resident room’s air circulating with mold particles which was not a healthy environment to resident. Per staff interviews, all staff denied the allegation. As mentioned above, Administrator had hired a carpet cleaning professional to shampoo and deep clean the carpet. Per LPA’s observation during the physical plant, the carpet looked clean. The room did not have the musty or damp / moldy smell during the visit. Therefore, there were not enough evidence to show staff failed to maintain a healthy environment for resident in care.

Based on the information obtained during the investigation, interviews with staff, residents, review of resident files and LPA's observation, the investigation did not reveal any evidence to support the allegations mentioned above.

Although the allegations may have happened or are valid, there is not preponderance of evidence to prove the alleged violations did or did not occur, therefore, the allegation is UNSUBSTANTIATED.

An exit interview was conducted with Gil and findings were discussed. A copy this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Bonnie Tao
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025

LIC9099 (FAS) - (06/04)

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