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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275202056
Report Date: 09/16/2021
Date Signed: 09/16/2021 04:51:27 PM

Document Has Been Signed on 09/16/2021 04:51 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
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:
09/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:12 AM
MET WITH:Mark Castillo, ADMTIME COMPLETED:
12:44 PM
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At 11:12AM, licensing Program Analyst (LPA) Steve Chang arrived at the facility. Upon arrival, LPA met with administrator (ADM) Mark Castillo, and addessed the purpose of today's visit to ADM. ADM conducted the infection control/prevention screening, took LPA's body temperature, then checked LPA in the visitor log book.

LPA observed the COVID-19 posters in facility. Hand sanitizers were observed at many places in facility. LPA toured the facility inside out with ADM. LPA inspected the offices, break room, living room, dining room, and medication room. There are 10 resident shared rooms for females, and 10 resident shared rooms for males. Each shared room can have two residents. Every two shared room have one bathroom for residents. There are two common restrooms for staff in facility.

LPA inspected the kitchen and checked the food supplies. Two days perishable foods and seven days non perishable foods were observed sufficient. LPA inspected the PPE supplies. PPE supplies were observed sufficient. The beds in the shared rooms were observed 6 feet apart. All the staff were observed wore masks. Not all the trash cans in facility are with covers. ADM stated the facility will fix this issue. LPA inspected the backyard of the facility. The ground surface is even. There is no obstruction in backyard.

LPA discussed and reviewed LIC808 with ADM, ADM stated all the staff and residents are fully vaccinated.

No citation was issued for today's inspection. Exit interview was conducted with ADM. This report was provided to ADM to review and to sign. A copy of this report was emailed to ADM
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2021
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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