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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005984
Report Date: 08/19/2024
Date Signed: 08/19/2024 12:12:18 PM


Document Has Been Signed on 08/19/2024 12:12 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 LIVINGFACILITY NUMBER:
306005984
ADMINISTRATOR:LOMEDA, RONA DFACILITY TYPE:
740
ADDRESS:7571 WYOMING STTELEPHONE:
(562) 569-8914
CITY:WESTMINSTERSTATE: CAZIP CODE:
92683
CAPACITY:122CENSUS: 23DATE:
08/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Rona LomedaTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. At around 8:15 PM LPA Tea was greeted and granted entry into the facility by a facility staff and explained the reason for the visit. Administrator (AD) Rona Lomeda arrived shortly to assist with the visit. The facility is licensed for 122 non-ambulatory residents, with a hospice waiver for twenty five. Currently there are 23 residents, of which five are on hospice during today's visit.

At around 8:43 AM LPA Tea reviewed six resident files and five staff files. Resident files and staff files contained all required documentation. Upon review of records, the facility is up to date with required quarterly fire drill, which was last conducted in August 6, 2024. AD Lomeda current certificate expires on October 06, 2025.

LPA Tea along with AD Lomeda toured the facility at 9:54 AM. LPA toured the physical plant, checked food service, and the first aid kit. The facility is a two-story building that consists of 30 resident bedrooms on each floor with shared Jack and Jill bathrooms between each room. There are shower rooms, main activity area, dining room, kitchen, medication room, staff office spaces, small activities area for dementia residents and outdoor courtyard patio area in the middle of the building. LPA observed smoke detectors/carbon monoxide in common areas and bedrooms are operational monitored by a third party service company. LPA observed cameras in the common area with no sound. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, and shower was free of mold/mildew. Water temperature measured around 114. F degrees. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including bandages, tweezers, thermometer, and scissors. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit.

Annual continuation on LIC809-C

SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Michael TeaTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2024
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: 08/19/2024
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Fire extinguishers were fully charged throughout the facility. LPA toured the outside grounds and there is ample seating underneath a shaded patio area in a courtyard style outdoor area. Staff hold special occasions outside in the courtyard patio area and have an outside grill for barbecuing. Also residents garden little plants in pots.

There is emergency food and water stored in the kitchen pantry storage closet. Facility provides several activities that is displayed on a giant calendar in the hallway that is updated often. Residents like to play bingo everyday. At the time of the visit, LPA observed residents doing morning exercise and singing karaoke.

LPA reviewed medication storage and administration. Medications are stored and secured in a medication room. Medications are being administered per physician order. LPA interviewed residents regarding their quality of care and spoke to staff present regarding care provided.

Based on the observation made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with Administrator Rona Lomeda and a copy of this report LIC809, along with the 809-C, LIC858, and LIC859 were read and provided to the facility.

SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Michael TeaTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2024
LIC809 (FAS) - (06/04)
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