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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603366
Report Date: 10/18/2021
Date Signed: 10/18/2021 04:53:33 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 RETREATFACILITY NUMBER:
198603366
ADMINISTRATOR:QUEZADA, JESSEFACILITY TYPE:
740
ADDRESS:9956 SHILOH AVETELEPHONE:
(562) 755-7464
CITY:WHITTIERSTATE: CAZIP CODE:
90603
CAPACITY:6CENSUS: 4DATE:
10/18/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Cynthia TadeoTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Jose Villalobos made and unannounced Annual inspection focused on Infection Control. On today’s visit LPA met with Administrator Cynthia Tadeo and the purpose of the visit was discussed. As a part of the inspection, LPA used the inspection tool, reviewed (4) client records and medications, also (2) staff records.

The facility is a single story home located in a residential area and contains the following: living room, closed 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. LPA toured the facility between 1:15pm-2pm. Adequate accommodations observed throughout facility. Hallways and doorways Free and clean of obstruction and debris. Bedroom #1-#6 observed with required furnishings. 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. Required linen/supplies which include, pillowcase, fitted sheet, blankets, bedspreads. Mattress pads were observed. Food supply observed. 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 & Detectors Electrical & Battery operated. All tested and working. carbon monoxide detectors tested and operational. (2) Fire extinguishers observed and up to date. Alarm systems were observed on all exit doors. Appliances observed and operational. Locked cabinet for toxins observed. Water temperature within required temperatures. LPA completed visit with the Inspection Tool focused on Infection Control.



No deficiencies cited on this visit and a copy of report was furnished
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2021
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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