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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603366
Report Date: 04/14/2025
Date Signed: 04/22/2025 09:37:35 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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
04/09/2025 and conducted by Evaluator Sanjay Vaid
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250409100907
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:
04/14/2025
UNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Cynthia Tadeo-House ManagerTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff did not provide a refund upon resident’s death
INVESTIGATION FINDINGS:
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*** This licensing report issued on 04/22/2025 supersedes that licensing report dated 04/14/2025. LPA Vaid obtained additional information; however, the investigation findings will remain the same****
On 04/14/2025, Licensing Program Analyst (LPA) Vaid conducted a initial 10-day complaint visit to the facility. Upon arriving at the facility, LPA met with caregiver Elizabeth Taylor allowed entry into facility and contacted the House Manager Cynthia Tadeo who joined shortly after. LPA discussed and explained the purpose of today’s visit. Spoke with licensee Jeese Quezada via phone.
LPA toured the physical plant along with Elizabeth Taylor and did not observe any Health and Safety concerns. LPA obtained resident/ staff roster, copy of resident 1 (R1) identification and admissions agreement.
Continued on 9099C.........
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025
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 3
Control Number 28-AS-20250409100907
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SHILOH RETREAT
FACILITY NUMBER: 198603366
VISIT DATE: 04/14/2025
NARRATIVE
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Regarding the allegation: Staff did not provide a refund upon resident’s death. It is alleged that the facility has not refunded the remaining prorated amount back to R1’s family upon their death within fifteen (15) days of R1’s death. Three (3) out of three (3) staff interviewed denied this allegation. S1 stated the amount of the refund was processed by the facility licensee on 04/11/2025 and sent out via USPS. The determined amount the facility refunded the prorated amount back to the family. Three (3) out of three (3) residents interviewed could not corroborate this allegation. Witness 1 (W1) stated upon the death of their family member on 11/12/2024, the family cleaned out and vacated R1’s belonging from the facility by 11/12/24. Same day after the death of R1.
R1’s lodging for private room and was paid in advance and the contract was effective 10/24/24 to 11/23/24. Payment was agreed and paid in advance for each month on the 24th going forward. Under the Admissions Agreement and Contract page 1 states 'This Agreement shall be in effect from month-to-month, unless and until it is terminated as set forth below'. According to the Admissions Agreement and Contract under section 19, page 10 of the Termination of Agreement states that an RCFE “ this agreement will be terminated immediately upon the death of the resident and payment will be owed until the room is vacated by any and all the residents’ personal belongings. Refunds in case of death will be processed with fifteen (15) days”. R1’s belongings were vacated by family on 11/12/2024.
According to W1, facility fees were paid in advance from the 24th of each month to the next. Facility fee payment was made 10/24/24 until 11/23/24. After R1 passed on 11/12/24 and all personal belongings were moved from the facility on 11/12/24. The facility did not determine the refund amount from the monthly advanced payment within fifteen (15) days. According to the admissions agreement the facility is not in compliance its own contract agreement made with R1’s family. Facility to refund the prorated amount to R1’s responsible party/family member for the period 11/13/24 through 11/23/24.
Therefore, based on LPA’s, interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations, (Title 22, Division 6 & Chapter 8), are being cited on the attached LIC 9099D.

Exit interview was conducted and copy of this report and appeals rights were left with Jesse Quezada, Administrator.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20250409100907
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: SHILOH RETREAT
FACILITY NUMBER: 198603366
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/14/2025
Section Cited
HSC
1569.652(c)
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Admission Agreements 1569.652 Refund conditions.(c)A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued...to entity contractually responsible for the fees or, if the deceased resident paid the fees, to the resident’s estate, within 15 days after the personal property is removed.
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Licensee to produce proof of entire prorated refund by 04/25/2025.
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This requirement not met as evidence by: Based on interviews and record review, licensee failed to refundR1's monies with 15 days after R1's belonging were removed and after R1's death.
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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: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025
LIC9099 (FAS) - (06/04)
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