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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603366
Report Date: 09/02/2025
Date Signed: 09/02/2025 03:28:27 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:
09/02/2025
UNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Jesse Quezada - Administrator TIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Facility is not keeping accurate records of resident medication.
INVESTIGATION FINDINGS:
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** This report supersedes the original complaint investigation report dated 8/21/2025. The reason for the supersede and the subsequent visit is to change the deficiency for Section 87506 from Type A to Type B, all other findings remain the same.”

Licensing Program Analyst (LPA), Bennette Pena conducted a subsequent visit to supersede the report dated 08/21/2025. LPA met with the Administrator, Jesse Quezada and explained the purpose of the visit.
The investigation consisted of the following: On 08/21/2025, LPA toured the facility and obtained a copy of the staff & resident rosters. LPA reviewed and obtained Resident #1 (R1) – Resident #2 (R2) pertinent files. LPA also obtained and reviewed the Corrective Action Plan (CAP) issued by Eastern Los Angeles Regional Center (dated 08/07/2025) and interviewed the Administrator.
During today’s visit, LPA delivered the superseded report for the allegation listed above.
****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: 09/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2025
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-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: 09/02/2025
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.

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.

Deficiency cited on the attached LIC9099-D. Exit interview was conducted and a copy of this report was provided to Jesse Quezada, 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: 09/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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: 09/02/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/09/2025
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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** This report supersedes the original complaint investigation report dated 8/21/2025 to change the deficiency for Section 87506 from Type A to Type B, findings remain the same.”

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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 a potential health, safety or personal rights risk to residents in care.
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Administrator shall provide in-service training to all staff on how to properly document the Medication Administration Record (MAR), as well as develop a policy requiring that (2) people verify medication records. Administrator to send a copy of the training log, along with the topics covered, and a sign-in sheet of staff who participated to CCL/LPA by POC due date.

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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: 09/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3