<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197606145
Report Date: 06/06/2026
Date Signed: 06/06/2026 04:29:49 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
12/29/2025 and conducted by Evaluator Glenn Trueman
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20251229105321
FACILITY NAME:ARCADIA GARDENS RETIREMENT HOTELFACILITY NUMBER:
197606145
ADMINISTRATOR:PAMELA PARSONSFACILITY TYPE:
740
ADDRESS:720 W. CAMINO REALTELEPHONE:
(626) 574-8571
CITY:ARCADIASTATE: CAZIP CODE:
91007
CAPACITY:200CENSUS: 152DATE:
06/06/2026
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Pamela ParsonsTIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff mismanaged residents' medications.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Glenn Trueman conducted an unannounced subsequent complaint investigation visit at the facility regarding the above allegation. LPA met with Administrator Pamela Parsons and explained the reason for the visit.
The initial visit was conducted on1/08/26 and included the following:
LPA requested copies of staff/resident roster. LPA reviewed file for Resident (R1) and received copies of identification and emergency sheet, admission agreement, and physician’s report. LPA interviewed Director of Nursing Suzana Zadourian and Staff S1 telephonically.
Documentation named Narrative Charting was also submitted for 12/27/25 -12/30/25.
Medication List for Resident R1 was submitted for 12/10/25- 01/09/26.
At today's visit 6/6/26 interviews were conducted with Administrator Pamela Parsons, and Staff S2 - Staff Staff S5. Interviews were conducted with Resident's R1- R15.
In regards to the allegation Staff mismanaged residents' medications, based on interviews conducted and information gathered Director of Nursing Suzana Zadourian confirmed that there was a medication error

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Glenn Trueman
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2026
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 5
Control Number 28-AS-20251229105321
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 GARDENS RETIREMENT HOTEL
FACILITY NUMBER: 197606145
VISIT DATE: 06/06/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
in which Resident R1 was administered medication by a nurse after mistakenly being identified as Resident R2.
Stated that R1's identify was not verified and was thus given R2's medication.
Afterwards staff reviewed the medications that were administered to R1 and they were not serious medications in being stomach medications and that R1 would have to wait a number of hours to take the medications that are always prescribed to R1.
Staff S1 confirmed that there was a mismanagement of R1's medication and that it was corrected the same evening.
Staff S2 stated that there was a mix up in which Resident R1 was given in error Resident R2's medication.
Staff S3 stated that she had mistakenly mixed up Resident R1 and R2 and that R1 by error was given R2's Medication.
Administrator revealed that the staff did communicate that R1 was given R2's medication, but R1 was given the correct meds the same evening.
Interview with R1 who stated that there was 1 time that they administered medication incorrectly and had given him R2's medication by mistake. Stated he did get his prescribed medication shortly thereafter.
Interviews were conducted with Resident's R2- R15 who stated that they had received their medication and that they were never given incorrect medication belonging to another resident.
Document Narrative Charting lists 12/17/25 notes regarding a medication error involving R1 mistakenly being administered medication that was prescribed to R2.
Based on records reviewed 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.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Glenn Trueman
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
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
12/29/2025 and conducted by Evaluator Glenn Trueman
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20251229105321

FACILITY NAME:ARCADIA GARDENS RETIREMENT HOTELFACILITY NUMBER:
197606145
ADMINISTRATOR:PAMELA PARSONSFACILITY TYPE:
740
ADDRESS:720 W. CAMINO REALTELEPHONE:
(626) 574-8571
CITY:ARCADIASTATE: CAZIP CODE:
91007
CAPACITY:200CENSUS: 152DATE:
06/06/2026
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Pamela ParsonsTIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not ensure that resident(s) received their medications as necessary.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
In regards to the allegation Staff did not ensure that resident(s) received their medications as necessary, based on interviews conducted and information gathered it was revealed by Director of Nursing Suzana Zadourian that Resident R1 did receive medication that same evening.
Said the doctor was consulted and informed staff that it was fine to administer medication to R1 that same evening and 3 hours later.
Stated that family member of R1 were at the facility ensuring that R1 did get R1's prescribed medication. Also said that R1 and R2 never missed any doses of medication.
Staff S1 stated that R1 and R2 never missed any doses of medication.
Administrator revealed that an error did occur, and staff did ensure that R1 was given the correct medication as necessary. Also R2 never missed any doses.
Resident's R2-R15 all stated that staff are very efficient in administering medication. All stated that they had never been given incorrect medication that belonged to another resident.
All stated that they had never missed a dose of their medication and that the process has gone smoothly.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Glenn Trueman
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20251229105321
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 GARDENS RETIREMENT HOTEL
FACILITY NUMBER: 197606145
VISIT DATE: 06/06/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Resident R1 stated that his prescribed medications were given to him shortly after the incorrect medication was given.
R2 stated that staff pick up his meds and also give him his meds. Said 1 thing he doesn't have to worry about is medication because staff does a great job.
Also said that staff has never missed giving him his doses of medication each day.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.
An exit interview was conducted and a copy of this report was discussed and provided to facility Executive Director Pamela Parsons.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Glenn Trueman
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20251229105321
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 GARDENS RETIREMENT HOTEL
FACILITY NUMBER: 197606145
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/06/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/07/2026
Section Cited
CCR
87465(a)(4)
1
2
3
4
5
6
7
Incidental Medical and Dental Care
(a) A plan for incidental medical and dental care shall be developed by each facility.The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
1
2
3
4
5
6
7
The licensee shall conduct medication training regarding medication administration and how to ensure medications are dispensed to the correct resident at all times.
Training date to be submitted by POC due date and a signed log of those who attended once completed.
8
9
10
11
12
13
14
The licensee shall assist residents with self administered medications as needed.
This requirement is not met as evidenced by Resident R1 being administered incorrectly R2's medication which poses an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
Training was conducted on 12/29/25 Proper Medication Administration
1/3/26 Communication and Confidentiality
and Proper Procedures.

Deficiency cleared.
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.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Glenn Trueman
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5