374602201-3-29-2024-08-AS-AROS-D3TS2A-20240329132913

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374602201
Report Date: 03/29/2024
Date Signed: 03/29/2024 01:29:18 PM

Document Has Been Signed on 03/29/2024 01:29 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	CASA DEL CIELO		FACILITY NUMBER:	374602201
ADMINISTRATOR:	VIRGILIA REBOSURA		FACILITY TYPE:	740
ADDRESS:	6173 ADELAIDE AVE		TELEPHONE:	(619) 286-2794
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92115
CAPACITY:	6	CENSUS:	DATE:	03/29/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:39 AM
MET WITH:	Licensee Virgilia Rebosura		TIME COMPLETED:	01:40 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Amy Rodgers, made an unannounced visit to conduct the required One-Year Inspection to ensure substantial compliance with Title 22 regulations. LPA Rodgers was granted entry into the facility by Care Giver Sherwin Sanchez, after identifying herself and stating the purpose of the inspection. Later Licensee Virgilia Rebosura joined the visit. LPA was accompanied Licensee Virgilia Rebosura during a tour of the facility. Tour was conducted inside and out and included a sample of resident bedrooms as well common areas. No bodies of water are on premises. Passageways were free from obstructions. According to Licensee Rebosura there are no weapons and/or ammunition stored on the premises. No delayed Egress or secured perimeter doors were present. Resident's room temperatures were within a comfortable range. Each resident had clean and sufficient bed linens. All extra linens, towels, and washcloth were present All residents’ rooms were equipped with required furnishings. Lighting was present in the bedrooms. Residents’ bathrooms were observed to be sanitary and operational. Toilets and showers were equipped with grab bars. Hot water temperature in residents’ bathrooms were compliant. [CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Amy Rodgers	TELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2024

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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: CASA DEL CIELO	FACILITY NUMBER: 374602201
	VISIT DATE: 03/29/2024

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CONTINUED FROM LIC 809]

Facility has a two-day supply of perishable food and a seven-day supply of nonperishable food items. Food was observed to be properly stored and labeled. Chemicals and cleaning supplies were stored in a locked closet and outside storage area. The medication is secured and is in a locked medication cabinet and medications were labeled and kept in compliance with label instructions.

Staff records review verified that all staff records were complete and compliant. Staff records review verified that all staff have a current First Aid certificate and CPR certificates Resident records were reviewed and confirmed compliant. Administrator’s certification is current. LPA reviewed the theft and loss policy and procedures. LPA interviews with Director Rebosua confirm residences are provided with assistance necessary for medical and dental appointments. LPA reviewed the theft and loss policy and procedures.

No deficiencies were cited at the time of visit. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs.

An exit interview was conducted, this report was discussed with Licensee Virgilia Rebosura , a copy along with Licensee/Appeal Rights (LIC 9058 01/2106), and their signature on this form acknowledges receipt and a copy of the report was given to the Licensee Virgilia Rebosura..

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Amy Rodgers	TELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2024

LIC809 (FAS) - (06/04)

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