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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603824
Report Date: 12/10/2024
Date Signed: 12/10/2024 11:47:18 AM

Document Has Been Signed on 12/10/2024 11:47 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 VILLAGEFACILITY NUMBER:
198603824
ADMINISTRATOR/
DIRECTOR:		ACHARYA, NIRJARAFACILITY TYPE:
740
ADDRESS:607 WEST DUARTE RDTELEPHONE:
(626) 447-6070
CITY:ARCADIASTATE: CAZIP CODE:
91007
CAPACITY: 200CENSUS: 78DATE:
12/10/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Virgilio Agas, current facility Administrator,
Adam Zenou, CEO;
Moises Bercovich, Co-CEO;
Nirjara Acharya, VP- Operations;
Kevin Avalos, VP- Plant Operations;
Jose Gonzales, VP- Culinary;
Perry Burge, Regional Director of Culinary;
Jonathan Lara, Regional Director of Plant operation.		TIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Tao conducted an announced pre-licensing inspection. An application was submitted to CCLD on 10/24/24 for a change of ownership. LPA met Virgilio Agas, the current facility Administrator, and Arcadia Operations LLC’s officers including Adam Zenou, CEO; Moises Bercovich, Co-CEO; Nirjara Acharya, VP- Operations; Kevin Avalos, VP- Plant Operations; Jose Gonzales, VP- Culinary; Perry Burge, Regional Director of Culinary; Jonathan Lara, Regional Director of Plant operation. The applicant is Arcadia Operations LLC. The facility was previously licensed to Goldwater Sag Holdings, LLC with facility # 198603401.

Applicant applied for Residential Care Facility for the Elderly to serve the Elderly for 60 years and older. The requested capacity is 200 which including 190 non-ambulatory residents and 10 may be bedridden. Facility may have 30 residents with Hospice wavier. Applicant has a Dementia Care program in application.

Structure:
The facility is a stucco structure with 91 bedrooms, 91 bathrooms, 1 TV room, an administrative office, a restaurant style kitchen, a laundry room, a coin laundry room, a janitor storage room, an activity room, a dining room and two elevators. There is a covered patio area on the premises. The resident bedrooms are spacious and will easily accommodate the client's furnishings. Passageways, walkways, stairs and patios are free from obstructions. The entrance and side areas are free of hazards and debris.

Signal system:
Facility has a signal system. It operates properly. (-continued LIC 809 C -)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/10/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 198603824
VISIT DATE: 12/10/2024
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Bedrooms for Residents:
Bedroom has a chair, nightstand, adequate lighting, adequate closet and drawer space. Bedrooms are spacious and allow for easy passage between and comfortable for usage of assistant devices such as walkers.

Bathrooms:
All bathrooms have a working toilet, wash basin, bathtub/shower. Bedrooms for non-ambulatory residents are accommodated for residents in a wheelchair.

Linens & Hygiene Supplies:
Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen stored in storage room.

Emergency Phone Numbers, Exit Plan & Menu:
Emergency Disaster Plan is posted at the lobby near the entrance. Menus are available for review.
Free landline telephone and mobile phones are available for residents’ use and operable.
Nineteen fire extinguishers are available in the facility. They are located near kitchen door mounted on wall, hallways of each floor and TV lounge room. They are fully charged and last service was on 11/7/24.

Food Service:
Dishes, cups and flat ware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are stored in a locked drawer in the kitchen. Food supply adequate stored and consists of two days of perishable and two weeks of non-perishable. Dishwasher in kitchen properly installed and functioning.

(-continued in LIC 809 C -)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 198603824
VISIT DATE: 12/10/2024
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Smoke Detectors:
Smoke detectors are located in residents’ rooms. They are operational and not hard wired. Carbon monoxide detectors located in hallway of each floor and are operational.

Appliances:
Stove burners, oven, microwave, washer, and dryer working. There are two refrigerators in the kitchen including a walk-in refrigerator and one additional refrigerator for food storage. Each refrigerator has a measured temperature of at least 45 degrees Fahrenheit for appropriate food storage. Freezer is at (0) zero degrees Fahrenheit. The residence is equipped with central air and heat and each client bedroom is individually climate controlled. The temperature is in a range of 68 to 75 degrees Fahrenheit.

Toxins:
Poisons, toxins, and cleaning supplies are locked in a room and inaccessible to residents.

Water Temperature:
Tested at 114.5. degrees Fahrenheit.

Medications, First-Aid Kit & Book:
Medication cabinets and carts were locked in the medication room and not accessible to the residents.

Residents & Staff Files:
Applicant will not handle cash resources for residents. Records of staff and clients shall be stored in a locked cabinet in administrator’s office and the section has been inspected along with the available records present. The facility has Liability insurance coverage.

Reading Material, Games, Equipment & Materials:
The facility has board games, books, bingo games, karaoke and other recreational materials for the residents’ use, commensurate with the plan of operation. (- continued in LIC 809 C -)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 198603824
VISIT DATE: 12/10/2024
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Pool:
Facility has no pool. Bodies of water is located at the entrance which is not accessible to residents.

Fire clearance:


Fire Clearance with 0 ambulatory, 190 non-ambulatory and 10 bedridden was approved on 11/07/24.
Residents’ bedrooms # 101- #119 are designated for bedridden rooms.

Component III:
Applicant requested to waive the Component III due to the applicant had done it from other pre-licensing visits.

An exit interview was conducted with Adam and Nirjara, and a hard copy was provided.

No issues or deficiencies were observed.

Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAU Analyst assigned to their application.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024
LIC809 (FAS) - (06/04)
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