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Inspection visit

complaint

SHILOH RETREATLicense 1986033664 citations on this visit
4 citations recorded

Inspector’s narrative

What the inspector wrote

The investigation revealed the following: Allegation: “Staff mismanaged resident medication.” I t 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. Allegation: "Facility is not keeping accurate records of resident medication." I t 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. " I t is alleged that d uring 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.

Citations

4 citations recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 87211(a)(1)(D)Type B

    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: 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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  • 87465(c)(2)Type A

    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: 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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  • 87506(a)Type A

    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: 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.

  • 87465(h)(5)Type A

    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: 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

FAQ · About this visit

Common questions about this visit

What happened during the August 21, 2025 inspection of SHILOH RETREAT?

This was a complaint inspection of SHILOH RETREAT on August 21, 2025. 4 citations were issued: 3 Type A (serious) and 1 Type B.

Were any citations issued to SHILOH RETREAT on August 21, 2025?

Yes, 4 citations were issued (3 Type A, 1 Type B). The first citation was for: "87211 Reporting Requirements..(a) Each licensee shall furnish to the licensing agency such reports as the Department may..."

What type of inspection was this?

This was a complaint inspection. Complaint inspections are triggered when someone reports a concern about the facility to CCLD.

SourceView on CCLDView original report

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Data from CCLD public records. Last updated . If you believe any information is inaccurate, report it here.