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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603366
Report Date: 08/21/2025
Date Signed: 08/21/2025 03:32:17 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
08/13/2025 and conducted by Evaluator Bennette Pena
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250813145506
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: 5DATE:
08/21/2025
UNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Jesse Quezada - Administrator
Cynthia Tadeo - Co-Administrator		TIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff mismanaged resident medication.
Staff did not follow reporting requirements.
Facility is not keeping accurate records of resident medication.
Residents medication is not being stored in original container.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Bennette Pena conducted the initial complaint investigation for the allegations listed above. Upon arrival at 9:50am, no one was home to let the LPA in. Administrator was called and informed LPA of their arrival time (1:30pm) at the facility. At 2:00pm, Administrator Jesse Quezada and Co-Administrator, Cynthia Tadeo arrived, met with LPA and explained the purpose of the visit.

The investigation consisted of the following: LPA toured the facility and obtained a copy of the staff & resident rosters. LPA reviewed and obtained Resident #1 (R1) – Resident #2 (R2) / SJ MC files such as Face sheet (ID and Emergency Info.), Physician’s report, Medication Administration Records (June-July 2025) and Incident Report (06/25/2025). LPA also obtained and reviewed the Corrective Action Plan (CAP) addressing the above allegations issued by Eastern Los Angeles Regional Center (dated 08/07/2025). Administrator is in agreement with the CAP findings, has signed and will be complying with them. LPA interviewed the Administrator. Staff and clients are out in the community celebrating an event; therefore, not interviewed.****CONTINUED ON LIC 9099-C***

Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2025
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 6
Control Number 28-AS-20250813145506
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/21/2025
NARRATIVE
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The investigation revealed the following:

Allegation: “Staff mismanaged resident medication.” It is alleged that during an unannounced visit by the Regional Center multiple discrepancies in medication administration were observed, including missing medications from the blister packs and medication being dropped and replaced with doses from the following day's blister pack without proper documentation. Administrator was interviewed and corroborated the allegation. During Regional Center's initial unannounced visit to the facility on June 25, 2025, Administrator stated that Regional Center discovered discrepancies in medication administration for R1-R2, including missed medications in the blister packs and medications that were dropped and replaced with doses from the following day's blister pack without proper documentation. Following the instructions of the Regional Center, the Administrator stated that they filed an incident report with CCL and the Regional Center on the same day. The Regional Center conducted an unannounced follow-up visit to the facility in July 2025 after reviewing discrepancies in the reports submitted for R1–R2. The Administrator explained to them the reasons behind the identified medication issues via email correspondence. The administrator has agreed with the Regional Center’s findings, as stated in the Corrective Action Plan (CAP) dated 08/07/2025, and has signed and stated they would comply with it, supporting the allegation.

Allegation: “Staff did not follow reporting requirements.” It is alleged that the facility failed to report incidents concerning multiple medication administration discrepancies for R1-R2. Administrator was interviewed and corroborated the allegation. Administrator stated that they submitted the incident report to CCLD and the Regional Center following the Regional Center’s instructions during their visit to the facility in June 25, 2025. Administrator indicated that the incident report should have been submitted right after the staff noticed the errors/discrepancies, but they had failed to do so. Based on the interview and the Corrective Action Plan (CAP) dated 08/07/2025 (agreed & signed by the Administrator), the allegation has been substantiated.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 28-AS-20250813145506
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/21/2025
NARRATIVE
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Allegation: "Facility is not keeping accurate records of resident medication." It is alleged that
during an unannounced visit by the Regional Center, they observed that staff members failed to sign the Medication Administration Record (MAR) on the correct date, and there were omissions in signing the MAR altogether. Administrator was interviewed and corroborated the allegation. Administrator stated that in June 25, 2025, Regional Center conducted an unannounced visit and discovered several medication errors for R1-R2, including staff failing to sign the Medication Administration Record (MAR) on the correct date and failing to sign the MAR at all. Regional Center then instructed them to submit an incident report to CCL and Regional Center, which the Administrator submitted on the same day. The Regional Center made an unannounced follow-up visit in July 2025 after reviewing discrepancies in the SIR's submitted for R1-R2. Administrator explained the reasons behind the identified medication issues to the Regional Center. Administrator agreed with the Regional Center’s findings, as stated in the Corrective Action Plan (CAP) dated 08/07/2025, has signed and stated they would comply with it, supporting the allegation.

Allegation: "Residents medication is not being stored in original container." It is alleged that during an unannounced visit by the Regional Center, they observed instances of pre-pouring medications prior to administration. Administrator was interviewed and corroborated the allegation. Administrator stated that the Regional Center made an unannounced visit in June 25, 2025 and discovered numerous medication errors for R1-R2, including instances in which medications were pre-poured before being administered. Following the instructions of the Regional Center, the Administrator stated that they filed an incident report with CCL and the Regional Center on the same day. After reviewing discrepancies in the reports provided for R1-R2, Regional Center paid the facility an unannounced follow-up visit in July 2025. The administrator gave them a copy of the email conversation they had in June 2025, explaining the reasons behind the identified medication issues. Administrator agreed with the Regional Center’s findings, as stated in the Corrective Action Plan (CAP) dated 08/07/2025 and has signed and stated they would comply with it, supporting the allegation.

Based on LPA’s interviews and document reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.

Deficiencies cited on the attached LIC9099-D. Exit interview was conducted and a copy of this report was provided to Cynthia Tadeo, Co-administrator along with the Appeals Rights.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 28-AS-20250813145506
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/22/2025
Section Cited
CCR
87465(c)(2)
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87465 Incidental Medical and Dental Care
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.
This requirement is not met as evidenced by:
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Administrator shall conduct an In-Service Training to all staff on appropriate Medication Dispensing Procedures. Administrator to provide/submit a copy of the training log along with the topics discussed, and the sign in sheet of staff name who attended with the date to CCL/LPA by POC due date.
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Based on interview, records review, the Administrator did not comply with the section cited above in which staff missed medications in the blister packs and medications that were dropped and replaced with doses from the following day's blister pack without proper documentation for R1-R2 which poses an immediate health, safety or personal rights risk to residents in care.
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Deficiency Dismissed
Type A
08/22/2025
Section Cited
CCR
87506(a)
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87506 Resident Records..(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
This requirement is not met as evidenced by:
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Administrator shall conduct an In-Service Training to all staff on proper documentation of Medication Administration Record (MAR) and develop a policy to have (2) person verification of medication records. Administrator to provide a copy of the training log along with the topics discussed, and the sign in sheet of staff name who attended with the date to CCL/LPA by POC due date.
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Based on interviews, records review, the Administrator did not comply with the section cited above in which the staff failed to sign the Medication Administration Record (MAR) on the correct date, and omissions in signing the MAR altogether for R1-R2 which poses an immediate health, safety or personal rights risk to residents in care.
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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: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 28-AS-20250813145506
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/22/2025
Section Cited
CCR
87465(h)(5)
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87465 Incidental Medical and Dental Care..(h) The following requirements shall apply to medications which are centrally stored:(5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
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Administrator agreed to provide in-service medication training to all staff that assist with preparing and administering medications. A copy of the training materials, scheduled date of training and list of participants to be sent to LPA by POC due date.

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Based on interviews, records review, the Administrator did not comply with the section cited above in which there were instances of pre-pouring medications prior to administration for R1-R2 which poses an immediate health, safety or personal rights risk to residents in care
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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: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 28-AS-20250813145506
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/27/2025
Section Cited
CCR
87211(a)(1)(D)
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87211 Reporting Requirements..(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1)A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.
This requirement is not met as evidenced by:
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Administrator will conduct an in-service training to all staff regarding Reporting Requirements and sign in sheet of the training. Administrator will also send a self-certification indicating that he read, reviewed and understood Title 22 Regulations, Section 87211. Administrator to submit copy of the In service training and self certification to CCL/LPA by POC due date.
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Administrator did not comply with the section cited above in which the Administrator did not submit an incident report regarding multiple medication administration discrepancies for R1-R2 which poses a potential health, safety or personal rights risk to residents in care.


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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: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6