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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006516
Report Date: 10/22/2025
Date Signed: 10/22/2025 01:06:36 PM

Document Has Been Signed on 10/22/2025 01:06 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: 6DATE:
10/22/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:August RebollarTIME VISIT/
INSPECTION COMPLETED:
01:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Hanna Gough arrived at the facility to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA met with Caregiver August Rebollar and discussed the purpose of the visit. Caregiver informed LPA that the Administrator is currently flying back to California and will not be able to come to the facility for the visit. The facility currently has six residents in care.

The facility is a one story home with six resident bedrooms, one staff bedroom, six bathrooms, kitchen, two living rooms, attached garage and backyard. Facility appears clean, safe and sanitary. LPA observed the resident bedrooms to have the required components and furnishings. LPA observed a fresh supply of clean linens in the closet by the front door. LPA observed the resident restrooms to have toilet paper, paper towels and textured shower flooring. LPA tested the water to be between 123.2-124.0 degrees Fahrenheit. LPA observed Caregiver turn the water heater down during the inspection. LPA observed the kitchen to be clean and free of vermin. LPA observed a two day perishable and seven day non perishable food supply on hand. LPA observed the toxins to be locked under the kitchen sink. LPA observed the knives to be locked in a drawer next to the kitchen sink. LPA observed the centrally stored medication to be in a locked cabinet located in the dining room. LPA observed the garage to store an extra food supply and toxins and chemicals on separate shelves. LPA observed the garage to be locked and made inaccessible to residents in care. LPA observed the backyard to be free of debris and obstructions. LPA observed an accessory dwelling unit (ADU) that is being used as a staff bedroom that was not observed on the fire clearance. A civil penalty was assessed at the time of the inspection. LPA observed a shaded seating area in the backyard for resident use. LPA and Caregiver tested the carbon monoxide and smoke detectors and they were found to be operational.

Continue on 809-C

NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: Hanna Gough
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2025
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 10/22/2025 01:06 PM - It Cannot Be Edited


Created By: Hanna Gough On 10/22/2025 at 11:56 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: CELESTIAL GARDEN
FACILITY NUMBER: 306006516

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in LPA testing the water in resident bathrooms to be between 123.2-124.9 degrees Farenheit which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2025
Plan of Correction
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LPA observed caregiver turn the water heater down during the inspection. Licensee stated they will test the water for 5 consecutive days and send proof of water temperature to LPA by POC due date.
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 of 2 staff not having complete records on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2025
Plan of Correction
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Licensee stated they will gather all documents needed and send proof of staff files completed to LPA by 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.
Armando J Lucero
NAME OF LICENSING PROGRAM MANAGER:
Hanna Gough
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2025


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 10/22/2025 01:06 PM - It Cannot Be Edited


Created By: Hanna Gough On 10/22/2025 at 11:56 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: CELESTIAL GARDEN
FACILITY NUMBER: 306006516

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(c)(1)
Medical Assessment
(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 of 6 residents not having a medical assessment with TB test on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2025
Plan of Correction
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Licensee stated they will obtain medical assessments for residents in care and send proof to LPA by POC due date.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in not conducting a quarterly disaster drill which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2025
Plan of Correction
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Licensee stated they will conduct a disaster drill and send proof to LPA by 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.
Armando J Lucero
NAME OF LICENSING PROGRAM MANAGER:
Hanna Gough
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2025


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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: CELESTIAL GARDEN
FACILITY NUMBER: 306006516
VISIT DATE: 10/22/2025
NARRATIVE
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LPA reviewed staff files and 2 of 2 staff files were incomplete. LPA observed resident files and 3 of 6 residents did not have a medical assessment for review and 5 of 6 residents did not have an updated needs and services plan. LPA did not review an updated disaster plan. LPA reviewed resident medications and 2 of 6 residents have medications without prescriptions. All staff are background cleared and associated to the facility.

Based on today’s observations a civil penalty and citations are being assessed per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report, LIC 809D, 858, 859, technical violation, civil penalty, and appeal rights were left at the facility.

NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: Hanna Gough
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2025
LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 10/22/2025 01:06 PM - It Cannot Be Edited


Created By: Hanna Gough On 10/22/2025 at 12:48 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CELESTIAL GARDEN
FACILITY NUMBER: 306006516

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type A
Section Cited
CCR
87204(a)
(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specifications 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 termporary exceptions to the approved capacity.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews, the licensee did not comply with the section cited above in LPA observing an accessory dwelling unit (ADU) in the backyard used as a staff living space for the last 2 months which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/23/2025
Plan of Correction
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Licensee stated they will make it a storage space and dissassemble the furniture as specified during the pre-licensing or submit for a new fire clearance and put a sign on the door of the ADU saying do not enter until it has passed inspection and send proof to LPA by POC due date.
Type A
Section Cited
CCR
87465(c)(1)
(1) There is written direction from a physician, on a prescription blank, specifying the name of the resident, the name of the medication, all of the information in Section 87465(e), instructions regarding a time or circumstance (if any) when it should be discontinued, and an indication when the physician should be contacted for a medication reevaluation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 2 of 6 residents having over the counter medication without a physicians order which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/23/2025
Plan of Correction
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Licensee stated they will obtain orders or discontinue use of medications and send proof to LPA by 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.
Armando J Lucero
NAME OF LICENSING PROGRAM MANAGER:
Hanna Gough
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2025


LIC809 (FAS) - (06/04)
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