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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366425270
Report Date: 04/06/2023
Date Signed: 04/06/2023 01:06:58 PM


Document Has Been Signed on 04/06/2023 01:06 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: DATE:
04/06/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:02 AM
MET WITH:May Cabrera - AdministratorTIME COMPLETED:
01:09 PM
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On this day, Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to this facility to initiate the investigation and deliver findings of complaint number: 56-AS-20230330134902. During the investigation, technical violations were discovered.
    • LPA reviewed Resident 1 (R1) April 2023 medication record and found 8 medications scheduled for the evening or bedtime were marked as already administered.
    • Through kitchen observation and staff interview, LPA found that the facility does not have a modified menu for residents with diabetes.

An exit interview was conducted with and a copy of this report and LIC9102, and appeal rights were provided to Ms. May Cabrera.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2023
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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