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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366425270
Report Date: 09/13/2022
Date Signed: 09/13/2022 03:17:18 PM


Document Has Been Signed on 09/13/2022 03:17 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507



FACILITY NAME:ABRIA DEL CIELOFACILITY NUMBER:
366425270
ADMINISTRATOR:CRISELDA ESPIRITU SANTOFACILITY TYPE:
740
ADDRESS:1589 N. WATERMAN AVETELEPHONE:
(909) 884-4757
CITY:SAN BERNARDINOSTATE: CAZIP CODE:
92404
CAPACITY:240CENSUS: 135DATE:
09/13/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:37 PM
MET WITH:Cris Espiritu SantoTIME COMPLETED:
03:19 PM
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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced case management visit for a Health & Safety check in conjunction with complaint control number: 56-AS-20220912152449. LPA met with staff who granted entry to LPA and executive director (ED) Cris Espiritu Santo who was explained the nature of the visit.

LPA and Staff 1 (S1) toured the facility inside and outside. LPA and S1 observed residents in the lobby and residents in the shaded outdoor area. LPA and S1 observed outdoor and indoor passageways were kept free of obstruction. LPA Bueno did not observe imminent health & safety concerns.

During this visit, LPA observed that one of one physician's record is not up to date. A technical advisory is being issued as the facility has a pre-scheduled appointment for the resident. Refer to LIC 9102TV for violation. An exit interview was conducted where this report, LIC 9102TV, and appeal rights were discussed and provided to the ED Espiritu Santo.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2022
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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