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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005984
Report Date: 08/28/2024
Date Signed: 08/28/2024 12:31:55 PM


Document Has Been Signed on 08/28/2024 12:31 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:
08/28/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Reynard MalacaTIME COMPLETED:
12:35 PM
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Licensing Program Analyst (LPA) Lydia Martinez, made an unannounced visit the facility to conduct a Required 1-Year evaluation. LPA was greeted by MedTech Reynard Malaca who stated LPA Michael Tea conducted an Annual visit on 8/19/2024. LPA confirmed Annual visit was conducted by LPA Tea. LPA completed visit.

Exit interview conducted, LPA sent copy of this report to email on file.
SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) 748-2936
LICENSING EVALUATOR NAME: Lydia MartinezTELEPHONE: (714) 705-6004
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024
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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