306005984-7-28-2026-22-AS-HGOH-DWEQCT-20260728120340

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005984
Report Date: 07/28/2026
Date Signed: 07/28/2026 12:03:56 PM

Document Has Been Signed on 07/28/2026 12:03 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	CIELO VISTA SENIOR LIVING		FACILITY NUMBER:	306005984
ADMINISTRATOR/ DIRECTOR:	VIRGILIO AGAS		FACILITY TYPE:	740
ADDRESS:	7571 WYOMING ST		TELEPHONE:	(562) 569-8914
CITY:	WESTMINSTER	STATE: CA	ZIP CODE:	92683
CAPACITY: 122		CENSUS: 36	DATE:	07/28/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:15 AM
MET WITH:	Virgilio "Gil" Agas		TIME VISIT/ INSPECTION COMPLETED:	12:20 PM

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Licensing Program Analyst (LPA) Hanna Fuller made an unannounced visit to the facility to conduct the required annual inspection. LPA entered the facility and waited for staff at the front counter and observed the windows and doors to the reception office to be unlocked leaving the medication on the tables and in the fridges accessible. LPA met with Administrator (AD) Gil Agas and discussed the purpose of the visit.

The facility is a two-story building that consists of 30 resident bedrooms on each floor with shared Jack and Jill bathrooms. There are communal shower rooms, an activity area, dining room, kitchen, staff office spaces, laundry room and outdoor courtyard patio in the middle of the building. LPA observed the resident rooms to have all the required components and furnishings. LPA observed the bathrooms to have toilet paper and paper towels. The water tested between 105 and 120 degrees Fahrenheit. LPA observed shower rooms with multiple showers for resident use. All were equipped with non slip mats. LPA observed the old medication room to be used as storage with medications on the back shelves. The room was found to be unlocked and accessible to residents. Staff promptly locked it after discovery. LPA observed a locked housekeeping room where toxins and chemicals are stored. LPA observed the kitchen to be clean and free of vermin. A two day perishable and seven day non perishable food supply was on hand. The emergency food and water supply was observed to be in the kitchen pantry. The knives are in a kitchen drawer in the middle island with the kitchen door and window being able to lock after kitchen staff leave making them inaccessible to residents. All appliances were found to be operational. LPA observed the dining room with lunch being served to residents during the inspection along with activities being conducted. The activities area takes up the back of the dining room. LPA observed the medication to be stored in the reception office with the medication carts being locked.

Continue on LIC809C

Kevin Saborit-Guasch
Hanna Gough
	DATE: 07/28/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2026

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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CIELO VISTA SENIOR LIVING	FACILITY NUMBER: 306005984
	VISIT DATE: 07/28/2026

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Facility staff closed and locked a metal gate across the front of the room and locked the glass door that is accessible behind the gate securing the medications and leaving access to the reception counter through the front door and window. A completed first aid kit was observed. LPA observed the elevator to be operational. The second floor of the facility is empty and is not in use by residents. LPA observed the stairwells to have evacuation chairs. Fire extinguishers were observed throughout the facility charged and with a service date of November 10, 2025. An outdoor shaded seating area was observed with no debris or obstructions.

LPA reviewed staff files and no discrepancies were observed. LPA reviewed resident files and medications and no discrepancies were observed. LPA reviewed the last fire drill was conducted on July 6, 2026. LPA reviewed the fire alarms were last tested on December 5, 2025, by Mendez Electritech and passed. All staff present are background cleared and associated to the facility.

LPA provided AD with facility PIN so that annual fees can be paid online.

Based on today’s inspection a deficiency is being noted per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report along with LIC809D and appeal rights were left at the facility.

NAME OF LICENSING PROGRAM MANAGER: Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM ANALYST: Hanna Gough
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/28/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2026

LIC809 (FAS) - (06/04)

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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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Document Has Been Signed on 07/28/2026 12:03 PM - It Cannot Be Edited

Created By: Hanna Gough On 07/28/2026 at 11:44 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: CIELO VISTA SENIOR LIVING	FACILITY NUMBER: 306005984
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/28/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(2)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in LPA observing medications in the front reception office and old medication room to be unlocked with medications accessible, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/29/2026
	Plan of Correction
1 2 3 4	LPA observed staff used a metal gate that can lock across the front of the room and locked the door that is accessible behind the gate ensuring all medications are secure as well as locking the old medication room door. Licensee stated they will conduct an in service with staff and send to LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM MANAGER:

	Hanna Gough
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/28/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2026

LIC809 (FAS) - (06/04)

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