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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366425270
Report Date: 08/15/2024
Date Signed: 08/15/2024 11:55:36 AM


Document Has Been Signed on 08/15/2024 11:55 AM - 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: 134DATE:
08/15/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Executive Director Criselda Espiritu SantoTIME COMPLETED:
11:55 AM
NARRATIVE
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On 08/15/2024 at 9:35 AM, Licensing Program Analysts (LPAs) Melody Brown and Raquel Hernandez conducted an unannounced visit to the facility to commence a Case Management Deficiency. LPAs Brown and Hernandez were greeted and granted entrance by a staff member and LPAs Brown and Hernandez met with Executive Director (ED) Criselda Espiritu Santo. LPAs Brown and Hernandez identified and discussed the purpose of the visit and with ED Criselda Espiritu Santo.

During the quick tour of the facility, LPAs Brown and Hernandez observed that the facility does not have the required carbon monoxide alarm, LPAs Brown and Hernandez informed ED Criselda Espiritu Santo that deficiency will be issued as this poses an immediate health, safety and personal rights risk to residents in care.
ED Criselda Espiritu Santo verbalized understanding.

An exit interview was conducted where this report LIC809, LIC809D, and Appeal Rights were discussed and provided to ED Criselda Espiritu Santo.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 08/15/2024 11:55 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 CIELO
FACILITY NUMBER: 366425270

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/16/2024
Section Cited
HSC
1569.311

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Health and Safety Code 1569.311 Carbon monoxide detectors required; inspection. Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards...This requirement is not met as evidenced by:
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Licensee stated to obtain/purchase carbon monoxide detectors and submit proof to LPA Brown on Plan of Corretion (POC) due date.
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Based on observations and interview, the Licensee did not comply with the section cited above by not ensuring that the facility has the required carbon monoxide detectors which poses an immedaiate health, safety, and personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2