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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005984
Report Date: 05/12/2026
Date Signed: 05/12/2026 09:41:20 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/18/2026 and conducted by Evaluator Garlli Tat
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20260218172543
FACILITY NAME:CIELO VISTA SENIOR LIVINGFACILITY NUMBER:
306005984
ADMINISTRATOR:LOMEDA, RONA DFACILITY TYPE:
740
ADDRESS:7571 WYOMING STTELEPHONE:
(562) 569-8914
CITY:WESTMINSTERSTATE: CAZIP CODE:
92683
CAPACITY:122CENSUS: 33DATE:
05/12/2026
UNANNOUNCEDTIME BEGAN:
08:48 AM
MET WITH:Justin LeeTIME COMPLETED:
09:55 AM
ALLEGATION(S):
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Staff did not administer medication as prescribed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Garlli Tat made an unannounced visit to the facility to deliver the findings on the above allegation. LPA met with the Manager Justin Lee and explained the purpose of the visit.
During the investigation, LPA inspected the facility, interviewed staff and residents, and collected pertinent documents including staff roster, resident roster, physician’s report, face sheets, unusual incident reports, medication administration records, death certificate, and admission agreement.
The investigation revealed the following:

It was alleged that Staff did not administer medication as prescribed.

Resident #1 (R1) moved to the facility on May 18, 2025, and moved out of the facility on January 28, 2026. R1 passed away at the hospital on February 6, 2026, from acute cardiopulmonary arrest and pneumonia.
Continued on LIC9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Garlli Tat
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 22-AS-20260218172543
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: CIELO VISTA SENIOR LIVING
FACILITY NUMBER: 306005984
VISIT DATE: 05/12/2026
NARRATIVE
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Per review of Physician’s Report dated May 13, 2025, R1 was diagnosed with Dementia, Atrial fibrillation (AFib), and Osteoarthritis of right knee. R1 was transported to the hospital for labored breathing on January 19, 2026, at 8:50am and returned on January 22, 2026. Hospital records show R1 was referred to cardiothoracic surgery clinic for further evaluation. LPA reviewed the Medication Administration Record (MAR) dated January 2026. R1 was not administered Levothyroxine 25mcg on January 19, 2026, for their 5am dose. LPA reviewed incident report dated January 23, 2026. Per report, R1 was transported to the hospital after 4:21pm on this day, per request of family member. Based on review of MAR, R1 was not administered Levothyroxine 25mcg on January 23, 2026 at 5am. LPA interviewed 4 staff. Staff #4 (S4) reported that they administered Levothyroxine 25mcg on January 19 and January 22, 2026, but they did not initial the MAR. Three out of four staff interviewed reported that they always complete the MAR right after medication is administered. R1’s MAR shows that R1 did not receive Levothyroxine 25mcg on January 19 and January 23, 2026.

Based on evidence gathered, the preponderance of evidence has been met, therefore, the above allegation is found to be Substantiated. Violations are being cited per Title 22 of California Code of Regulations. See LIC9099-D for cited deficiencies.

An exit interview was conducted with the Manager and a copy of this report, (LIC9099, LIC9099-D), and Appeal Rights was provided to the facility representative.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Garlli Tat
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20260218172543
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CIELO VISTA SENIOR LIVING
FACILITY NUMBER: 306005984
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/12/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/13/2026
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement was not met as evidenced by:
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Licensee agrees to train all staff who administer medication to residents on CCR 87465 and to provide proof of training to LPA by the POC due date. Licensee submitted proof of training request on 05/06/2026.
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A review of records shows R1 did not receive Levothyroxine 25mcg on January 19 and January 23, 2026, which poses an immediate health and safety 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.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Garlli Tat
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3