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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275202056
Report Date: 12/07/2022
Date Signed: 12/19/2022 08:33:00 AM

Document Has Been Signed on 12/19/2022 08:33 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
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:
12/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator, Mark CastilloTIME COMPLETED:
03:30 PM
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On 12/07/2022, Licensing Program Analyst (LPA) V. Gorban arrived unannounced at the above facility to conduct an Annual Inspection- Infection Control. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility by staff, Ana Bides, administrator Mark Castillo, certification expiration 11/18/24, was notified over the phone of Licensing visit and arrived shortly.

Visitor log-in/temperature check station was observed upon entry. Hand sanitizer was readily available to residents and visitors. Facility has one entrance/exit point. Hand washing and other various Covid-19 related signs were observed in the common areas. Facility staff was observed with mask covering.

The facility was observed, with 20 female private rooms occupied and 20 male rooms on the opposite side of the facility, to be at a comfortable temperature, free of debris, in good repair, and no passageway obstructions or fire hazards were observed. Common areas were properly furnished and well-lit throughout. PPE were observed in a laundry room. A 2-day supply of perishable and 7-day supply of non-perishable food was observed to be properly stored and labelled. Fire extinguisher was observed with a service date of 10/13/2022 Resident's all bedrooms were observed to be adequately furnished with bed, dresser, and adequate lighting. Sample of residents file was reviewed for emergency contact and medication documentation. Facility utilizes electronic mars documentation for narcotics, prn and daily medications/prescriptions.

No deficiencies were observed. Administrator was provided the source to Title 22 and PINs update information.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2022
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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: CIELO VISTA
FACILITY NUMBER: 275202056
VISIT DATE: 12/07/2022
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Community Care Licensing (CCL) is always striving to have facility files that reflect the most accurate & up to date information for your facility. In an effort to maintain your facility file, please submit the most current & complete forms &/or information as identified below:

Adult Residential (ARF):


· LIC 308 Designation of Facility Responsibility
· -as applicable: LIC 309 Administrative Organization
· -as applicable: LIC 400 Affidavit Regarding Client/Resident Cash Resources
· -as applicable: LIC 402 Surety Bond
· LIC 500 Personnel Report
· LIC 610D Emergency Disaster Plan For Adult Residential Facilities
· LIC 9020 Register of Facility Clients/Residents


Please submit the above forms/information to Fresno CCL by: 01/27/2023.

As an operator of a Community Care Licensed facility it is your responsibility to be aware of and in compliance with all regulations, including Chaptered Legislation. Go to www.ccld.ca.gov to stay updated and informed.

SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2022
LIC809 (FAS) - (06/04)
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