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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604061
Report Date: 03/08/2024
Date Signed: 03/08/2024 01:00:52 PM

Document Has Been Signed on 03/08/2024 01:00 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 CIELOFACILITY NUMBER:
374604061
ADMINISTRATOR:ALLAN, BRETT KFACILITY TYPE:
740
ADDRESS:17737 HUNTERS RIDGE ROADTELEPHONE:
(619) 990-0543
CITY:SAN DIEGOSTATE: CAZIP CODE:
92127
CAPACITY: 6CENSUS: 6DATE:
03/08/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Caregiver Cristina FigueroaTIME COMPLETED:
01:10 PM
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Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Required Annual Inspection. The
LPA introduced himself and discussed the purpose of the visit with Administrator Ana Hurtado. The facility was licensed for a capacity of six (6), of which six (6) could be bedridden, and an approved hospice waiver for three (3).

During the annual visits, the LPA toured the interior and exterior of the facility, and inspected each room. The facility
was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms
contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens
and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and
equipment to facilitate dining, laundry, visitation, meetings, and client activities.

There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored.
Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to clients.
Medications were labeled, and stored in locked areas.

No pools, nor bodies of water were observed on the premises. Per staff, no firearms, nor ammunition were kept at the facility. Carbon monoxide detectors, facility telephone, fire extinguisher, and a first aid kit wee readily accessible. Required licensing postings were observed in visible areas of the facility.

LPA interviewed staff and reviewed multiple staff and client records/files. Technical assistance was provided to the administrator. During the annual inspection, the LPA discovered a staff member, who was witnessed providing care and supervision, was not background cleared. A review of the Departments Guardian system did not reveal a clearance for Staff #1 (S1). This deficiency was cited in an LIC 809D, a civil penalty was assessed, and a Plan of Correction was jointly formulated with Administrator Hurtado. (See LIC 809C for continuation of report.)
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2024
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 CIELO
FACILITY NUMBER: 374604061
VISIT DATE: 03/08/2024
NARRATIVE
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An exit interview was conducted with Administrator Hurtado, to whom a copy of this report, LIC 811, and the Licensee/Appeal Rights (LIC9058), were provided.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/08/2024 01:00 PM - It Cannot Be Edited


Created By: Sabel Martinez On 03/08/2024 at 12:07 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 CIELO
FACILITY NUMBER: 374604061

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87755(e)(1)
87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or, This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews and review of records, the licensee did not comply with the section cited above in for Staff #1 (S1),which poses an immediate health, safety or personal rights risk to 6 of 6 persons in care.
POC Due Date: 03/08/2024
Plan of Correction
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Administrator agreed to have S1 background cleared prior to returning to work. LPA witnessed S1 was not present during the annual continuation visit, therfeore, the Plan of Correction was cleared on 03/08/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Lizzette Tellez
LICENSING EVALUATOR NAME:Sabel Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2024


LIC809 (FAS) - (06/04)
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