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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005984
Report Date: 09/09/2026
Date Signed: 09/09/2026 11:31:57 AM

Document Has Been Signed on 09/09/2026 11:31 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:CIELO VISTA SENIOR LIVINGFACILITY NUMBER:
306005984
ADMINISTRATOR/
DIRECTOR:		VIRGILIO AGASFACILITY TYPE:
740
ADDRESS:7571 WYOMING STTELEPHONE:
(562) 569-8914
CITY:WESTMINSTERSTATE: CAZIP CODE:
92683
CAPACITY: 122CENSUS: 53DATE:
09/09/2026
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Virgilio Agas TIME VISIT/
INSPECTION COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analysts (LPAs) Hanna Fuller, Michael Tea and Taylor Simerly made an unannounced visit to the facility to gather resident documentation and conduct a health and safety check on residents in care. LPAs were greeted and granted entry by Administrator (AD) Virgilio Agas and discussed the purpose of the visit.

LPAs gathered resident documentation, toured the facility and observed residents in care relaxing and participating in activities.

LPAs observed Staff #1 (S1) who stated they are security and maintenance for the facility having a background clearance and association that is still in progress on Guardian. LPAs advised S1 and AD that staff cannot be working in the facility until their background clearance and association has been completely processed showing eligible in green in the guardian system. LPAs observed S1 gather their belongs and leave the facility.

Based on today's observations a deficiency and civil penalty for repeat violation was assessed for $1000. An exit interview was conducted and a copy of this report along with LIC 809D, LIC421IM, LIC811 and appeal rights were left at the facility.
Kevin Saborit-Guasch
Hanna Fuller
DATE: 09/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2026
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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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)
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Document Has Been Signed on 09/09/2026 11:31 AM - It Cannot Be Edited


Created By: Hanna Fuller On 09/09/2026 at 10:40 AM
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
, 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: 09/09/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/10/2026
Section Cited
CCR
87355(e)(2)

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87355(e)(2) Request a transfer of a criminal record clearance...
This requirement is not met as evidence by:
Based on record review and interview, the licensee did not comply with the section cited above in LPA observing Staff #1 did...
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LPA observed S1 leave the facility. Licensee to check all staff background clearances and send proof of all staff on the LIC500 to be associated with the facility and send a statement of understanding by POC due date to LPA.
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not have a criminal record clearance or association.This poses an immediate health, safety or personal rights risk to persons in care.
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A CIVIL PENALTY WAS ASSESSED.

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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.
Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM MANAGER:
Hanna Fuller
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2026


LIC809 (FAS) - (06/04)
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