198603366-10-13-2020-28-AS-JVIS-BUCTV4-20201013150318

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603366
Report Date: 10/12/2020
Date Signed: 10/13/2020 03:04:11 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
ADMINISTRATOR:	QUEZADA, JESSE		FACILITY TYPE:	740
ADDRESS:	9956 SHILOH AVE		TELEPHONE:	(562) 755-7464
CITY:	WHITTIER	STATE: CA	ZIP CODE:	90603
CAPACITY:	6	CENSUS: 0	DATE:	10/12/2020
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Administrator Jesse Quezada		TIME COMPLETED:	02:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Jose Villalobos and LPA Cheri Wilkerson conducted an announced tele-visit with Administrator Jesse Quezada. The purpose of the visit was to conduct the Pre-Licensing visit. An application was submitted to CCLD on 5/11/2020, for an Initial license of a Residential Care Facility for the Elderly. The requested capacity of 6 residents, (0) ambulatory, (6) non-ambulatory and (0) may be bedridden. Structure/Physical Plant: The facility is part of a single story home located in a residential area and contains the following: living room, fireplace, dining room, kitchen with refrigerator, oven, stove, dishwasher, sink/faucet, locked storage cabinet for sharps, (6) resident rooms, (2) bathrooms ; bathrooms with shower, toilets and washbasins. (1) office room with washer and dryer. A back yard with shaded area and seating for resident use. A detached garage inaccessible to residents for storage. The residence is equipped with central air and heating. Residence also equipped with tankless water heater. Accommodations: Adequate accommodations observed throughout facility. Lighting: Sufficient Lighting throughout. Hallway and Doorways: Free and clean of obstruction and debris. Night-lights observed in hallways leading to bathroom. Resident Rooms: Bedroom #1 is for (1) non-ambulatory resident. Bedroom #2-6 is for (1) non-ambulatory resident each. All bedrooms are equipped with: overhead lighting, chair, night stand, lamp in addition to overhead lighting, large drawer, and closet space. Bathrooms: Bathroom #1 is attached to bedroom #1 and has working toilet, wash basin, shower, and nonskid mats grab bars. Bathroom #2 is a large bathroom with (2) working toilets, (2) wash basins, and (2) showers, nonskid mats and required grab bars observed. Continued on LIC 809-C

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2020

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/12/2020

NARRATIVE

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Linens & Hygiene Supplies: Required linen/supplies which include, pillowcase, fitted sheet, blankets, bedspreads. Mattress pads were observed. Emergency Phone Numbers, Exit Plan & Menu: Facility has a working phone landline. There is (1) cordless phone for residents use. Fire Extinguisher 1 and 2 fully charged and up to date Food Service: All food and adequate utensils such as, dishes, cups, bowls and plates were observed. Knives, cutlery and other sharps inaccessible to residents are kept in a locked cabinet. Smoke Detectors & Fire Extinguishers: Detectors Electrical & Battery operated. All tested and working. carbon monoxide detectors tested and operational. (2) Fire extinguishers observed and up to date. Alarms: Facility to provide services to residents with Dementia. Alarm systems were observed on all exit doors and were tested and operational. Appliances: Stove burners and oven operational. Microwave, washer, and dryer are operational. Toxins: Locked/stored for staff use only. Hot Water Temperature: Measured at 110 degrees in the kitchen and 110 degrees in both bathrooms. Medications, First-Aid Kit & Book: Medications centrally stored and inaccessible to resident. First aid kit inspected which contains: thermometer, tweezers, scissors, antiseptic, bandages, gauze, and first aid manual which is available for staff use. Residents & Staff Files: Facility has a locked cabinet for resident and staff files. Files were observed. Reading Material, Games, Equipment & Materials, Postings: The facility has activity supplies and an activities calendar posted. Required wall postings observed. Bodies of Water: None. Pets: None. Fire clearance: Fire clearance was approved on 7/14/2020.

Component III:
LPA Villalobos conducted the Component III with Jesse Quezada on todays visit.

At the time of visit Administrator acquired a telephone for the facility. Phone line was tested and operational. Administrator also acquired a closed gate for the fireplace in the facility.

There are no other corrections needed. Physical plant of the facility is cleared and ready for licensure.

An exit interview was conducted over the tele-visit and a copy of this report has been furnished to the Jesse Quezada via email. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2020

LIC809 (FAS) - (06/04)

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