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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275202056
Report Date: 08/25/2021
Date Signed: 08/26/2021 09:37:17 AM

Document Has Been Signed on 08/26/2021 09:37 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:CIELO VISTAFACILITY NUMBER:
275202056
ADMINISTRATOR:MARK CASTILLOFACILITY TYPE:
735
ADDRESS:806 ELM AVENUETELEPHONE:
(831) 674-2180
CITY:GREENFIELDSTATE: CAZIP CODE:
93927
CAPACITY: 40CENSUS: 39DATE:
08/25/2021
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Mark Castillo, ADMTIME COMPLETED:
03:37 PM
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A Noncompliance meeting was conducted today via Microsoft Team Meeting. Present at the meeting were San Bruno Adult and Senior Care Regional Manager Vivien Helbling, Licensing Program Manager Romeo Manzano, Licensing Program Analyst Steve Chang, Jorge Mendez, Garrett Johnson, Regional Manager, and Facility Administrator Mark Castillo.

The purpose of the noncompliance meeting was to discuss the serious incident at the facility on 01/09/19 which resulted to a death of a resident and also a substantiated complaint finding was delivered on 12/12/19. A deficiency was issued that a staff did not seek timely medical service under Title 22 California Code of Regulation, 80075 Health Related Services (a).

Facility administrator was informed during non-compliance meeting that additional civil penalties per Health and Safety Code ยง 1548(d) for a violation that the Department determines result in the death at an adult residential facility, the civil penalty shall be fifteen thousand dollars ($15,000), pending review. Noncompliance Conference Summary LIC9111 and a compliance plan was established during the meeting.

Report was provided to Administrator Mark Castillo via e-mail for review and signature.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2021
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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