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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320375
Report Date: 11/15/2024
Date Signed: 11/15/2024 03:12:51 PM

Document Has Been Signed on 11/15/2024 03:12 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:CIELAFACILITY NUMBER:
198320375
ADMINISTRATOR/
DIRECTOR:		SHRAM, RONYFACILITY TYPE:
740
ADDRESS:17310 WEST VEREDA DELA MONTURATELEPHONE:
(917) 667-5303
CITY:PACIFIC PALISADESSTATE: CAZIP CODE:
90272
CAPACITY: 100CENSUS: 56DATE:
11/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Administrator – Rony ShramTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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On 11/15/2024, the California Department of Social Services (CDSS) – Community Care Licensing Division (CCLD) staff conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with Administrator – Rony Shram. CCLD staff explained the purpose of the visit and was accompanied by a staff member inside and outside the facility during this inspection.

This facility is licensed to serve 100 non-ambulatory adults ages 60 and above, of which 20 may be bedridden. The facility is approved for 20 hospice residents. The facility is approved for delayed egress. All facility units are approved for bedridden clients.

The Annual Licensing Fees are current.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2024
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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: CIELA
FACILITY NUMBER: 198320375
VISIT DATE: 11/15/2024
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The facility is a four-story building with two underground floors located in a residential street.
The first floor consists of: main entrance with lobby and front desk, office rooms, industrial kitchen, dining room, residential mail space, public restrooms, salon, activity room, bistro, and lounge area. The first floor also has the Dementia Care Unit with residential units, the botanical garden, kitchen, café, dining room area, and medication room.
The second floor consist of: a beauty bar, office rooms, lounge/library area, courtyard, public bathrooms, and residential units.
The third floor consist of: outside patio area, public bathrooms, and residential units.
The fourth floor consist of: residential units.
The first underground floor consists of: parking garage, theater room, gym, spa room, pool room, food storage, freezer room, fridge room, staff break room, and lactation room.
The second underground floor consist of: parking garage, resident storage, and storage rooms.
The facility has a total of 82 residential units, 99 bathrooms, and several indoor and outdoor common spaces with shaded seating.

The kitchen area has supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024
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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: CIELA
FACILITY NUMBER: 198320375
VISIT DATE: 11/15/2024
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Medications were safe, locked, and inaccessible. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. Documents are posted as mandated. Last Earthquake drill was conducted on 09/10/2024. There are several fire extinguishers around the premises, and they were last serviced on 09/27/2024. There are landline telephones on the premises. There is a videoconferencing device dedicated for client use in the computer room.

8 out of 82 residential units were checked. There is adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition. Bathroom toilets and water faucets worked properly, grab bars were secure, and a non-skid mat was in place. Adequate lighting and toiletries accessible to residents. This facility provides residents with hygiene products such as feminine napkins, nonmedicated soap, toilet paper, toothbrush, toothpaste, and comb.

5 staff records were reviewed, 5 out of 5 staff records had required documentation.
5 resident records were reviewed and, 5 out of 5 resident records had required documentation.

No deficiencies are being cited based on LPA observation and record review in accordance with the California Code of Regulations, Title 22.

An exit interview was conducted, and a copy of this report was left with the Administrator.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024
LIC809 (FAS) - (06/04)
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