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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603366
Report Date: 10/10/2024
Date Signed: 10/10/2024 12:38:42 PM

Document Has Been Signed on 10/10/2024 12:38 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:SHILOH RETREATFACILITY NUMBER:
198603366
ADMINISTRATOR/
DIRECTOR:		QUEZADA, JESSEFACILITY TYPE:
740
ADDRESS:9956 SHILOH AVETELEPHONE:
(562) 755-7464
CITY:WHITTIERSTATE: CAZIP CODE:
90603
CAPACITY: 6CENSUS: 5DATE:
10/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:52 AM
MET WITH:Cynthia Tadeo - House ManagerTIME VISIT/
INSPECTION COMPLETED:
12:52 PM
NARRATIVE
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Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced Required 1-year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Cynthia Tadeo, House Manager for the facility, and explained the purpose of the visit. There are five (5) non-ambulatory residents residing within the home.

The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Resident Rights/Information, Resident Records/Incident Reports, Food Service, Planned Activities, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs.

Infection Control:

· Infection control practices were observed.


· Infection control plan is on file.

Physical Plant/Environment Safety:

· The facility is a single-story home located in a residential neighborhood. It is licensed for a capacity of six (6) residents, six (6) of which may be non-ambulatory, and a hospice waiver approved for two (2) residents. The facility consists of a kitchen with dining area, a living room, an office which contains the facility’s washer and dryer, six (6) resident bedrooms, two (2) bathrooms of which restroom #1 had a hot water temperature of 106.7 Degrees Fahrenheit and restroom #2 had a hot water temperature of 105.2 Degrees Fahrenheit, and therefore the water temperature was within range. The facility also has a backyard that contains a shaded area and a storage shed. The facility was observed to be in good repair.


·The interior and exterior physical plant was inspected. Exit doors are free of any obstruction. The facility has two (2) fully charged fire extinguishers in the facility.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/10/2024 12:38 PM - It Cannot Be Edited


Created By: Erik Zaragoza On 10/10/2024 at 12:02 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SHILOH RETREAT
FACILITY NUMBER: 198603366

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87633(a)(1)
Hospice Care for Terminally Ill Residents
(a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility, when all of the following conditions are met: (1) The licensee has received a hospice care waiver from the department.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above in [count] out of 2 out of 5 clients, because the facility currently has a hospice waiver approved for 2 residents, however there are currently 4 residents whoare on hospice, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/07/2024
Plan of Correction
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Administrator is to ensure that the facility has an approved hospice waiver for the appropriate number of residents at all times. Administrator is to email a Hospice Waiver increase request letter to the LPA by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:David Sicairos
LICENSING EVALUATOR NAME:Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2024


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SHILOH RETREAT
FACILITY NUMBER: 198603366
VISIT DATE: 10/10/2024
NARRATIVE
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Operational Requirements:
· The Program Design was reviewed.

· Fire clearance was approved by LA County Fire Department for a capacity of six (6) residents, six (6) of which may be non-ambulatory, and a hospice waiver approved for two (2) residents.


· Care and supervision to meet the clients’ needs was observed.

Staffing:

· Three (3) full-time staff members provide care and supervision to the clients.

Personnel Records/Staff Training:

· Five (5) staff files were reviewed for criminal background clearance and training.


· All staff records reviewed have health a health screening with a Tuberculosis clearance, and all staff have First Aid/CPR trainings that are active.
· The administrator’s certificate expires on 5/1/2025.

Resident Rights/Information:

· Physician orders were reviewed for five (5) resident files.

· Medications were also reviewed for five (5) residents.

Resident Records/Incident Reports:

· Five (5) resident files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent, and medication records were reviewed.

Food Service:

· The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:

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

DATE: 10/10/2024
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SHILOH RETREAT
FACILITY NUMBER: 198603366
VISIT DATE: 10/10/2024
NARRATIVE
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Incident Medical and Dental:

· All residents have an Appraisal/Needs and Services Plan on file.

· Staff training was on file.

Disaster Preparedness:

· Emergency and Disaster Plan was publicly posted and found within the facility.

· The last emergency and disaster drill was conducted on 10/1/2024.

Planned Activities:

· Sufficient Space is provided to accommodate both indoor and outdoor activities.

· Sufficient equipment and supplies are provided to meet the requirements of the activity program.

Residents with Special Health Care Needs:

· There are four (4) residents who are currently receiving hospice services, however currently the facility license is only approved for a hospice waiver of two (2) residents.

· There is an adequate number of staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her appraisal.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiency observed during the visit is documented on the LIC809D page. Exit interview held and a copy of the report along with appeal rights were provided.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:

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

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