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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602201
Report Date: 04/17/2026
Date Signed: 04/17/2026 08:05:29 PM

Document Has Been Signed on 04/17/2026 08:05 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 CIELOFACILITY NUMBER:
374602201
ADMINISTRATOR/
DIRECTOR:		VIRGILIA REBOSURAFACILITY TYPE:
740
ADDRESS:6173 ADELAIDE AVETELEPHONE:
(619) 286-2794
CITY:SAN DIEGOSTATE: CAZIP CODE:
92115
CAPACITY: 6CENSUS: 6DATE:
04/17/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Licensee/Administrator Virgilia RebosuraTIME VISIT/
INSPECTION COMPLETED:
08:30 PM
NARRATIVE
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Licensing Program Analysts (LPA) Dang Nguyen and Eryn Kane made an unannounced visit to conduct a Required Annual Inspection. LPAs were welcomed by, identified themselves to, and discussed the purpose of the visit with Licensee/Administrator Virgilia “Gigie” Rebosura.

According to the facility’s license, the facility has a maximum capacity for six (6) residents, of whom all may be ambulatory or non-ambulatory, but none may be bedridden. Per LPA observation, LIC602 Physician’s Reports, and staff interviews: During today’s inspection, there were a total of six (6) residents in care, of whom one (1) was ambulatory, four (4) were non-ambulatory, and one (1) was bedridden [Resident #1 (R1)]. [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] The presence of this bedridden resident represents a violation of the conditions/limitations of the facility license and fire clearance. The facility’s license did not include endorsements for delayed-egress doors or secured perimeter, and neither of these were present.

LPAs reviewed care records for all current residents and personnel files for all active staff. LPAs, accompanied by Licensee/Administrator, also toured the interior and exterior of the facility, and inspected all common areas, restrooms, and resident bedrooms.

The facility did not have a working carbon monoxide alarm, as required. In the facility’s dining room area were two (2) disinfecting chemical sprays and one (1) container of disinfecting chemical wipes, unsecured/unlocked. [CONTINUED ON LIC 809-C, 1 of 2]
NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Dang Nguyen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/17/2026
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 10
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 10
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: 04/17/2026
NARRATIVE
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[CONTINUED FROM LIC 809] In the facility’s backyard was one (1) container of disinfecting chemical wipes, one (1) pitchfork with metal points, one (1) full length shovel with metal blade, and one (1) full-length metal pry bar tool, unsecured/unlocked. According to LIC602 Physician’s Reports, five (5) of the six (6) residents in care [R1 through Resident #5 (R5)] had Dementia, and their respective physician had determined that the resident should not have direct access to the above items.

Beyond the above, the facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were working. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. The facility’s ambient internal temperature was complaint at 74 F. Hot water temperature at taps used by residents for grooming were compliant in temperature: Bathroom #1 Sink was 109.2 F and Bathroom #2 Sink was 109.4 F. Refrigerators and freezers to preserve perishable food were also all compliant in temperature. There was at least two (2) days of perishable food, and at least seven (7) days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present.

Medications were labeled, as required, and stored in locked areas. There were no fireplaces of open-faced heaters accessible to residents. Confidential records were stored in locked areas. No pools or similar bodies of water were observed on the premises. Per the Licensee, no firearms or ammunition are kept at the facility. Smoke alarms, night lights, emergency lighting, and facility telephone were all working. The facility’s fire extinguishers were serviced within the last twelve (12) months. Required licensing postings were observed in visible areas of the facility. There were reserve toiletry supplies, spare linens, and Personal Protective Equipment (PPE) present. Licensee presented proof of current business liability insurance.

During review of resident records, LPAs observed, and manager interview confirmed: For four (4) of six (6) residents (R3 through R6), Licensee did not have the name, address, and telephone number of the residents’ dentist to be called in the event of an emergency, as required. R1 and R2 had supplemental oxygen, R2 had a urinary catheter, and R4 had Diabetes (all of which are “Restricted Health Conditions” in the RCFE setting, per regulation). However, Licensee did not have written proof that four (4) of four (4) direct care staff [Staff #1 (S1) through Staff #4 (S4)] had yet received hands-on training from a licensed professional on administration of oxygen, catheter care, and diabetes, which was required before care for these conditions began. [CONTINUED ON LIC 809-C, 2 of 2]
NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Dang Nguyen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2026
LIC809 (FAS) - (06/04)
Page: 3 of 10
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: 04/17/2026
NARRATIVE
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[CONTINUED FROM LIC 809-C, 1 of 2] R1, R2, and R3 were each receiving hospice care services. However, Licensee did not have written proof that four (4) of four (4) direct care staff (S1 through S4) received “training specific to the current and ongoing needs of the individual resident receiving hospice care” from the resident’s hospice agency personnel (such as the assigned nurse case manager) prior to the start of the hospice care, as was required. Licensee also did not have proof/documentation that they held a care meeting/conference with the responsible person and other appropriate parties for six (6) of six (6) residents (R1 through R6), for the purpose of reviewing and updating the resident’s written record of care / care plan, within the last twelve (12) months, as was required.

During review of staff records, LPAs observed, and manager interview confirmed: Licensee did not have proof of current First Aid Training for one (1) of four (4) direct care staff (S2). Licensee did not have written proof that three (3) of four (4) direct care staff (S2, S3, and S4) had completed at least twenty (20) hours of ongoing training within the last year, to include at least eight hours on dementia care and at least four hours on postural supports, restricted health conditions, and hospice care, as required. Licensee did not have written proof that four (4) of four (4) staff who assist residents with medication administration had received at least eight (8) hours of ongoing medication in-service training within the last twelve (12) months, as required.

Eight (8) deficiencies were cited per California Code of Regulations, Title 22, and two (2) deficiencies were cited per California Health and Safety Code (refer to the LIC809-D pages). Since one of these deficiencies represents a violation of the facility’s prior-approved fire clearance, an immediate civil penalty of $500 was charged/assessed (refer to the LIC421-IM page). Plans of Correction were jointly developed with the Licensee. LPAs also provided Technical Assistance (TA) regarding knob protectors for safeguarding the facility’s kitchen range and periodic measuring of residents’ body weights (refer to the LIC9102-TA pages).

An exit interview was conducted with Licensee/Administrator Virgilia “Gigie” Rebosura, to whom a copy of this report, the LIC 809-D pages, the LIC421-IM page, the LIC9102-TA pages, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during today’s visit.
NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Dang Nguyen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2026
LIC809 (FAS) - (06/04)
Page: 4 of 10
Document Has Been Signed on 04/17/2026 08:05 PM - It Cannot Be Edited


Created By: Dang Nguyen On 04/17/2026 at 06:35 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: CASA DEL CIELO
FACILITY NUMBER: 374602201

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.311
Regulations
Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observation, Licensee did not have at least one carbon monoxide detectors in the facility which meets the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. This posed an immediate safety risk to 6 of 6 residents (R1 through R6) in care.
POC Due Date: 04/18/2026
Plan of Correction
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2
3
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Licensee agreed to purchase and install one (1) plug-in carbon monoxide alarm, and to send a copy of the the purchase receipt to LPA, by the POC due date.
Type A
Section Cited
CCR
87204(a)
Limitations -Capacity and Ambulatory Status
(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records and manager interview, in retaining 1 of 6 residents (R1) who was bedridden, the Licensee operated the facility beyond the conditions and limitations specified on the facility's license. This posed an immediate safety risk to persons in care.
POC Due Date: 04/20/2026
Plan of Correction
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2
3
4
By the POC due date, Licensee agreed to submit an LIC200 Application with LIC999 Facility Sketch to the CCLD San Diego Regional Office (CCLASCPSanDiegoRO@dss.ca.gov; cc'ing LPA Nguyen), requesting the following change in capacity: A total of (6) residents, of whom one (1) may be bedridden and five (5) may be non-ambulatory. In the event bedridden capacity is not approved during the subsequent fire inspection, Licensee agreed to issue a 30-day notice to R1, so long as R1 remains bedridden.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2026


LIC809 (FAS) - (06/04)
Page: 5 of 10
Document Has Been Signed on 04/17/2026 08:05 PM - It Cannot Be Edited


Created By: Dang Nguyen On 04/17/2026 at 06:35 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: CASA DEL CIELO
FACILITY NUMBER: 374602201

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, Licensee did not ensure that cleaning solutions and tools which could pose a danger to residents were in locked storage and not left unattended. This posed an immediate health and safety risk to 6 of 6 residents (R1 through R5) in care.
POC Due Date: 04/17/2026
Plan of Correction
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During today's visit, LPA handed the cleaning solutions and tools to staff to be locked away. This resolved the immediate risk. No further Plan of Correction was formed.
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2026


LIC809 (FAS) - (06/04)
Page: 6 of 10
Document Has Been Signed on 04/17/2026 08:05 PM - It Cannot Be Edited


Created By: Dang Nguyen On 04/17/2026 at 06:35 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: CASA DEL CIELO
FACILITY NUMBER: 374602201

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review and manager interview, Licensee did not ensure that 1 of 4 staff (S2) records contained proof of current First Aid Training from persons qualified by such agencies as the American Red Cross. This posed a potential health risk to 6 of 6 residents (R1 through R6) in care.
POC Due Date: 05/17/2026
Plan of Correction
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3
4
Licensee agreed to have S2 complete First Aid Training. Licensee agreed to E-mail a copy of S2 new biennial first aid card to LPA, by the POC due date.
Type B
Section Cited
HSC
1569.69(b)
Other Provisions
(b) Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review and manager interview, Licensee did not ensure that 4 of 4 medication-passing staff (S1 through S4) had completed 8 hours of in-service training on medication-related issues within the the last twelve (12) months. This posed a potential health risk to 6 of 6 residents (R1 through R6) in care.
POC Due Date: 05/17/2026
Plan of Correction
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4
Licensee agreed to have S1 through S4 each finish 8 hours of annual training on medicaiton-related topics. Licensee agreed to clearly document the training, and to send proof of completion to LPA, by the POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2026


LIC809 (FAS) - (06/04)
Page: 7 of 10
Document Has Been Signed on 04/17/2026 08:05 PM - It Cannot Be Edited


Created By: Dang Nguyen On 04/17/2026 at 06:35 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: CASA DEL CIELO
FACILITY NUMBER: 374602201

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(9)
Resident Records
(b) Each resident's record shall contain at least the following information: (9) Name, address and telephone number of physician and dentist to be called in an emergency.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review and manager interview: For 4 of 6 residents (R3, R4, R5, and R6), Licensee did not have in their record the name, address, and telephone number of a dentist to be called in an emergency. This posed a potential health risk to persons in care.
POC Due Date: 05/17/2026
Plan of Correction
1
2
3
4
Licensee agreed to communicate with necessary parties to update the Facesheets for R3 through R6. If a resident does not have a preferred dentist, Licensee may list a default mobile professional who can be called for emergencies, until a preferred one is provided. Licensee agreed to E-mail the updated Facesheets for R1 through R5 to LPA, by the POC due date.
Type B
Section Cited
CCR
87613(a)(2)(A)
87613 General Requirements for Restricted Health Conditions: “(a) Prior to admission of a resident with a restricted health condition, the licensee shall: (2) Ensure that facility staff who will participate in meeting the resident’s specialized care needs complete training provided by a licensed professional sufficient to meet those needs. (A) Training shall include hands-on instruction in both general procedures and resident-specific procedures.” This requirement was not met, as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review and manager interview, 3 of 6 residents (R1, R2, and R4) each had a restricted health condition, but Licensee did not have proof that 4 of 4 direct care staff (S1 through S4), who participate in meeting the resident’s specialized care needs, completed training provided by a licensed professional, which included hands-on instruction in both general procedures and resident-specific procedures. This posed a potential health risk to persons in care.
POC Due Date: 05/17/2026
Plan of Correction
1
2
3
4
Licensee agreed to find a licensed professional (such as a nurse) to lead a hands-on in-service training for all current caregivers on at least the following Restricted Health Conditions which are present at the facility: Supplemental Oxygen Administration, Urinary Catheter Care, and Diabetes (including signs and symptoms of hypoglycemia/hyperglycemia and diabetic emergencies requiring medical intervention). Licensee agreed to E-mail the staff training sign-in sheet to LPA, by the POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2026


LIC809 (FAS) - (06/04)
Page: 8 of 10
Document Has Been Signed on 04/17/2026 08:05 PM - It Cannot Be Edited


Created By: Dang Nguyen On 04/17/2026 at 06:35 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: CASA DEL CIELO
FACILITY NUMBER: 374602201

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87467(a)(3)
Resident Participation in Decisionmaking
(a) Prior to, or within two weeks of the resident's admission, the licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident's preferences regarding the services provided at the facility. (3) The licensee shall arrange a meeting with the resident and appropriate individuals identified in Section 87467(a)(1) to review and revise the written record as specified, when there is a significant change in the resident's condition, or once every 12 months, whichever occurs first. Significant changes shall include, but not be limited to occurrences specified in Section 87463, Reappraisals.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review and manager interview, for 6 of 6 residents (R1 through R6), Licensee did not within the last 12 months arrange a meeting with the resident and required individuals to review and revise the resident's written record of care. This posed a potential health risk to persons in care.
POC Due Date: 05/17/2026
Plan of Correction
1
2
3
4
For R1 through R6 each, Licensee agreed to conduct a care conference with their responsible person (and visiting hospice agency personnel, if applicable) to review the resident's facility Plan of Care, updating it as needed. All parties to the meeting will sign. Licensee agreed to E-mail proof of care conference completion to LPA, by the POC due date. Going forward, Licensee agreed to facilitate such care conferences at least once every 12 months for each resident.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2026


LIC809 (FAS) - (06/04)
Page: 9 of 10
Document Has Been Signed on 04/17/2026 08:05 PM - It Cannot Be Edited


Created By: Dang Nguyen On 04/17/2026 at 06:35 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: CASA DEL CIELO
FACILITY NUMBER: 374602201

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87633(b)(6)(B)
Hospice Care for Terminally Ill Residents
(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: (6) Identification of the training needed, which staff members need this training, and who will provide the training relating to the licensee's responsibilities for implementation of the hospice care plan. (B) The hospice agency will provide training specific to the current and ongoing needs of the individual resident receiving hospice care and that training must be completed before hospice care to the resident begins.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review and manager interview, Licensee did not ensure that the hospice agency trained 4 of 4 direct care staff (S1 through S4) on 3 of 6 residents (R1, R2, and R3, who were each under hospice care) current and ongoing individual care needs. This posed a potential health risk to persons in care.
POC Due Date: 05/17/2026
Plan of Correction
1
2
3
4
Licensee agreed to coordinate with the hospice agency for R1, R2, and R3 to have their nurse lead an in-service training for current facility staff, seperately covering R1, R2, and R3's hospice care plan and the current and their ongoing care needs. Licensee agreed to E-mail the training sign-in sheets to LPA, by the POC due date.
Type B
Section Cited
HSC
1569.625(b)(2)
“(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.” This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review and manager interview, Licensee did not ensure that 1 of 4 staff (S2, S3, and S4) had completed 20 hours of training within the last twelve (12) months, of which 8 hours were required to be on dementia care and of which 4 hours were required to be on postural supports, restricted health conditions, and hospice care. This posed a potential health and personal rights risk to 6 of 6 residents (R1 through R6) in care.
POC Due Date: 05/17/2026
Plan of Correction
1
2
3
4
Licensee agreed to have S2, S3, and S4 each finish 20 hours of annual training (ensuring at least 8 hours are on dementia care and at least 4 hours are on "postural supports, restricted health conditions, and hospice care"). This training battery should also include an in-service on the facility’s LIC610E Emergency Disaster Plan and use of Personal Protective Equipment (PPE). Licensee agreed to clearly document the training, and to send proof of completion to LPA, by the POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2026


LIC809 (FAS) - (06/04)
Page: 10 of 10