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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006516
Report Date: 11/18/2024
Date Signed: 11/18/2024 04:52:19 PM

Document Has Been Signed on 11/18/2024 04:52 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:CELESTIAL GARDENFACILITY NUMBER:
306006516
ADMINISTRATOR/
DIRECTOR:
NGUYEN, DIANEFACILITY TYPE:
740
ADDRESS:429 S SHIELDS DR.TELEPHONE:
(949) 266-4403
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 6CENSUS: 4DATE:
11/18/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:25 PM
MET WITH:Diane Nguyen, Administrator/LicenseeTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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Licensing Program Analysts (LPAs) Rose Ruppert and Fred Arias conducted an announced follow-up pre-licensing visit at 3:25 PM. LPAs were greeted and granted by staff and met with Diane Nguyen, Administrator/ Prospective Licensee (LE) and explained the purpose of our visit.

LPAs toured the facility and inspected the following areas that needed to be corrected for licensure. All non-ambulatory room exits had working auditory alarms. LPA Arias measured six of six bathroom temperatures and all bathrooms measured below 120 degrees Fahrenheit. Shower grab bars were installed in bathrooms #2 and #3. LE purchased a new stove and LPA Ruppert confirmed all stove burners self ignite. The handle to the exit sliding glass door is repaired.

LPAs inspected the exterior and confirmed the Additional Dwelling Unit (ADU) was used as storage. All furniture was disassembled and stored. LPA Ruppert recommended to LE to add any additional family members to Guardian if they will be spending more than ten hours a week at the facility.

LPAs conducted the Component Three Orientation with LE. LE was notified that the final application approval will be issued by the Centralized Applications Bureau in Sacramento. An exit interview was conducted and a copy of this report was provided to Licensee.


SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2024
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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