306005984-8-25-2021-22-AS-RMAZ-C68PWS-20210825114114

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005984
Report Date: 08/25/2021
Date Signed: 08/25/2021 11:41:24 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	CIELO VISTA SENIOR LIVING		FACILITY NUMBER:	306005984
ADMINISTRATOR:	LOMEDA, RONA D.		FACILITY TYPE:	740
ADDRESS:	7571 WYOMING ST		TELEPHONE:	(562) 569-8914
CITY:	WESTMINSTER	STATE: CA	ZIP CODE:	92683
CAPACITY:	122	CENSUS: 0	DATE:	08/25/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Rona Lomeda		TIME COMPLETED:	12:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Ruth Martinez conducted an announced visit to the facility for the purpose of a pre-licensing evaluation. LPA arrived was greeted and granted entry to the facility by Rona Lomeda, Director. An initial application to operate an Adult Residential Facility for the Elderly, age 60 years and over, for (122) capacity, (0) ambulatory, (122) non-ambulatory, and (0) bedridden clients was submitted to CCL on 03/23/2021. LPAs observed the following: Structure: Facility is a two story building with 64 apartment style resident bedrooms, dining room, and kitchen, front office, medication room, physical therapy room, doctor’s office, counseling room, activities room on first floor and a library, chapel on the second floor. There is a courtyard with seating for the residents. The resident bedrooms will accommodate residents' furnishings. Signal System: Central air/heating system installed with a central panel to control entire building. Bedrooms Residents: Bedrooms accommodate non-ambulatory residents only. There are 30 shared bedrooms on the first floor and 25 shared bedrooms, 3 private bedrooms, and 6 apartment style 2 bedrooms on the second floor. All bedrooms have half a bathroom. Continued on LIC809-C

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CIELO VISTA SENIOR LIVING	FACILITY NUMBER: 306005984
	VISIT DATE: 08/25/2021

NARRATIVE

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Bathrooms:
All bathrooms have a working toilet, wash basin, and walk-in shower.

Linens and Hygiene Supplies:
Adequate supply of linens is stored in storage closet.

Emergency Phone Numbers, Exit Plan, and Menu:
Posted and readily available for review in the dining room.

Food Service:

Adequate supply of 7 day non-perishable and 2 day perishables will be stored in the kitchen with a storage room in kitchen for surplus goods.

Smoke and Carbon Monoxide Detectors:
Smoke and carbon monoxide alert systems are hardwired with a sprinkler system maintained by Electric Tech and A & A Fire Inc.

Fire Extinguisher:
Fully charged and mounted throughout the facility.

Fire Clearance:
Approved on 07/22/2021
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Appliances:
Restaurant style kitchen with all appliances, washer and dryers in laundry unit are clean and noted to be operational.

Toxins:
Locked and stored in a storage closet.

Continued on LIC809-C

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021

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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CIELO VISTA SENIOR LIVING	FACILITY NUMBER: 306005984
	VISIT DATE: 08/25/2021

NARRATIVE

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Water Temperature:
Tested and recorded at 111.2-112.1 degrees Fahrenheit in bathroom on first and second floor.

Medications, First Aid Kit & Manual:
First Aid kit with guide is stored in medication room. Medication carts will be utilized for medication with locks.

Resident and Staff Files:
Records will be kept in medication room.

Reading Material, Games, Equipment, & Materials:
The facility has activities that commensurate with their plan of operation.

Component III:
Conducted at the Pre-Licensing visit, information provided about how to operate the facility within substantial compliance.

Applicant was reminded that it is required to notify LPA, within 5 business days of admitting the first resident. This notification may be done by phone, email or fax.

All items reviewed during the visit are in compliance. Facility appears to be ready for licensure. Accordingly, LPA will submit file for approval to CCL Supervisor.
Exit interview was conducted and a copy of this report was left with the applicant.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021

LIC809 (FAS) - (06/04)

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