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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603366
Report Date: 12/16/2024
Date Signed: 01/06/2025 09:27:43 AM

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
03/05/2024 and conducted by Evaluator Glenn Trueman
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240305101027
FACILITY NAME:SHILOH RETREATFACILITY NUMBER:
198603366
ADMINISTRATOR:QUEZADA, JESSEFACILITY TYPE:
740
ADDRESS:9956 SHILOH AVETELEPHONE:
(562) 755-7464
CITY:WHITTIERSTATE: CAZIP CODE:
90603
CAPACITY:6CENSUS: 3DATE:
12/16/2024
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Staff Charlene MunozTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff did not prevent resident from developing a stage 4 pressure injury while in care
INVESTIGATION FINDINGS:
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The purpose of this report 01/06/24 is to remove confidential information from the 9099C dated 12/16/24. Licensing Program Analyst (LPA) Glenn Trueman made an unannounced subsequent visit to the facility and was greeted by Staff Charlene Munoz and explained the reason for the visit.
The purpose of the visit is to deliver findings for the above allegation.
The initial visit was conducted on 03/06/24 by LPA Mora and was a Health and Safety Check.
In regards to the allegation Staff did not prevent resident from developing a stage 4 pressure injury while in care, the Investigations Branch (IB) Investigator Heidy Bendana from the California Department of Social Services conducted an investigation that was completed on 08/09/24.
The investigation included interviews with facility staff and residents, and medical records obtained from Eden Hospice, PIH Home Health, Whittier Police Department Incident Report Request and notes and visit notes e-mailed by the House Manager.
The investigation provided sufficient evidence to substantiate neglect/lack of care and supervision against Shiloh Retreat. Interviews, notes, home health medical records and hospice medical records indicated Resident R1's pressure ulcers worsened.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024
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-20240305101027
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: SHILOH RETREAT
FACILITY NUMBER: 198603366
VISIT DATE: 12/16/2024
NARRATIVE
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Resident R1 reported that facility staff were not repositioning her every two hours as instructed by PIH Home Health. Per Preplacement Appraisal, Resident R1 had a stage 2 bed sore at the time of admission into the facility. Facility administration and staff knew Resident R1 had a pressure wound because Resident R1 was admitted to the facility with a stage 2 pressure ulcer. Resident R1's pressure ulcers progressively worsened to a stage 4 on 11/6/2023, and small drainage was noted. On 11/10/2023, Resident R1's pressure ulcer was unstageable. Resident R1 was admitted into hospice on 3/7/2024, it was noted that Resident R1 had a stage 4 pressure ulcer in the coccyx and a stage 3 pressure ulcer in the sacral region. Per PIH Home Health medical records, staff S1 told the home health nurse to leave and that caregivers would do Resident R1's care. Staff S2 described R1's wounds as a deep hole that was red. Facility staff knew Resident R1 needed to be rotated every two hours and saw her wounds worsening however it is more likely than not that Resident R1 was not rotated every two hours, as instructed by Resident R1's medical team. PIH Home Health and Eden Hospice noted Resident R1's pain complaints. The facility failed to take appropriate actions to prevent Resident R1's pressure wounds from worsening; therefore, the allegation is substantiated.
Based on observations and interviews which were conducted and record review, 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 6 are being cited on the attached LIC 9099D.
Civil Penalty Assessed $500.

The licensee was informed that a civil penalty might be assessed based on Health and Safety Code 1569.49 (e)




NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20240305101027
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: SHILOH RETREAT
FACILITY NUMBER: 198603366
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/17/2024
Section Cited
CCR
87465(a)(1)
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Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed by each facility...: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.
This requirement is not met as evidenced by:
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Administrator will schedule training for staff on procedures, notifying responsible parties, and seeking medical care upon observing wounds in residents by POC due date 12/17/24, and will submit a copy of log, training description and duration of training by 12/31/24.
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Based on interviews and documents reviewed licensee did not ensure R1 was provided medical care in a timely manner after developing a Stage 4 pressure wound which poses an immediate risk to the persons health, safety, or personal rights of the persons in care.
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***An immediate Civil Penalty of $500.00 is being issued today, due to resident sustaining wound while in care. Refer to LIC 421IM*
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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.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024
LIC9099 (FAS) - (06/04)
Page: 3 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
03/05/2024 and conducted by Evaluator Glenn Trueman
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240305101027

FACILITY NAME:SHILOH RETREATFACILITY NUMBER:
198603366
ADMINISTRATOR:QUEZADA, JESSEFACILITY TYPE:
740
ADDRESS:9956 SHILOH AVETELEPHONE:
(562) 755-7464
CITY:WHITTIERSTATE: CAZIP CODE:
90603
CAPACITY:6CENSUS: 3DATE:
12/16/2024
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Staff Charlene MunozTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff did not assist resident with bathing
INVESTIGATION FINDINGS:
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The purpose of this report is to remove confidential information from the report dated 12/16/24.
Licensing Program Analyst (LPA) Glenn Trueman made an unannounced subsequent visit to the facility and was greeted by Staff Charlene Munoz and explained the reason for the visit.
The purpose of the visit is to investigate the above allegation and deliver findings for the above allegation.
At today's visit 12/16/24 Staff S1 was interviewed and Resident's R1-R3. Shower schedule for Resident R1 and Hospice Flowsheet for Resident R1 were reviewed.
The initial visit was conducted on 03/06/24 by LPA Mora and was a Health and Safety Check.
In regards to the allegation Staff did not assist resident with bathing, based on interviews conducted and information gathered it was revealed by Resident R1 that she has been showered or bathed at least 1x a week for the whole time she has been here.
Resident R2 and R3 stated they get bathed 2x a week.
Staff S1 stated that she had bathed Resident R1 2x a week.
Facility shower schedule documents Resident R1 being showered weekly from 03/24- 05/24.
Hospice flow sheet documents bed baths being given.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20240305101027
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: SHILOH RETREAT
FACILITY NUMBER: 198603366
VISIT DATE: 12/16/2024
NARRATIVE
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Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

An exit interview was conducted .
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5