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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603366
Report Date: 10/12/2023
Date Signed: 10/12/2023 04:29:04 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
10/03/2023 and conducted by Evaluator Jose Villalobos
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20231003163348
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:
10/12/2023
UNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Administrator Jesse QuezadaTIME COMPLETED:
03:20 PM
ALLEGATION(S):
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Staff did not accord resident dignity and respect while in care.
Staff does not respond to residents screams for assistance.
Staff does not ensure that resident's personal belongings are accessible to the resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced complaint investigation visit for the allegation(s) listed above. LPA Villalobos met with Administrator Jesse Quezada and the purpose of the visit was discussed.

On todays visit, LPA conducted the following: Toured the physical plant, Interviewed Staff #1-#4 (S1-S4) and residents #1-#5 (R1-R5), reviewed R1's file and collected documents from R1's related to their care plan. The investigation revealed the following:

In regards to the allegation "Staff did not accord resident dignity and respect while in care." it was alleged that S1 had left R1 undressed, exposed without assistance with the door open while completing other tasks. (4) of (4) Staff interviewed denied the allegation. (4) of (5) Residents interviewed could not corroborate the allegation... Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023
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 2
Control Number 28-AS-20231003163348
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/12/2023
NARRATIVE
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Interview with S1 denies leaving R1 undressed and exposed with their door open. LPA was not provided with proof that R1 was left unexposed with their door open in the facility. Interviews state that R1 is able to communicate with staff and even has a bell ringer to notify staff when they need assistance with anything.
Based on interviews conducted, as well as LPA observations there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

In regards to the allegation "Staff does not respond to residents screams for assistance." it was alleged that residents scream for assistance and S1 does not respond or assist residents. (4) of (4) Staff interviewed denied the allegation. (4) of (5) residents interviewed could not corroborate the allegation. Interviews show that there was a day, date not provided to LPA, where R1 asked for S1's assistance but S1 was in the process of assisted another resident and could not assist R1 immediately. Interviews state that S1 notified R1 that they would assist them once done with the other resident of the facility. Interviews also state that the only resident who yells out for help is R2 and that is because R2 is blind and gets confused. That is how R2 will call staff over. Staff interviewed denied that resident screams are ignored. Based on interviews conducted, as well as LPA observations there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

In regards to the allegation "Staff does not ensure that resident's personal belongings are accessible to the resident." it was alleged that S1 moves R1's portable table away from R1 making it inaccessible to R1. (4) of (4) Staff interviewed denied the allegation. (4) of (5) residents interviewed could not corroborate the allegation. Interviews show that R1 has a personal desk on wheels where they place some of their belongings such as the tv remote. Interviews with staff state that this table is never made inaccessible to R1 and that it is always by their bedside. It is moved to the side when there is care or assistance being provided to R1 so that it is not in the way, but it is put back when tasks are completed. LPA observed the table to be by R1's bedside throughout the visit. Based on interviews conducted, as well as LPA observations there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview was conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023
LIC9099 (FAS) - (06/04)
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