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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006516
Report Date: 10/29/2025
Date Signed: 10/29/2025 05:04:25 PM

Document Has Been Signed on 10/29/2025 05:04 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:
10/29/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:30 PM
MET WITH:August RebollarTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Hanna Gough arrived at the facility to conduct a Case Management Deficiencies inspection. LPA was greeted and granted entry by staff. LPA met with Caregiver August Rebollar and discussed the purpose of the visit.

LPA was informed that the Administrator (AD) will not be coming to the facility and that the caregivers were on their way to the doctors and could not assist LPA during the visit. LPA inquired about the one caregiver at the facility. Staff #1 (S1) informed LPA that they were hired through an agency and have only been at the facility for one day. S1 informed LPA that they were not given instructions before being left alone with the residents so they did not know how to assist LPA. LPA did not observe that S1 was background cleared and associated to the facility. An immediate civil penalty was assessed at the time of the visit. LPA waited for staff to return to the facility and observed S1 leave the facility property.

The AD informed LPA that they cannot assist at the facility and that they do not have anyone that they can send over to help. AD informed LPA that they will call the caregivers and have them return to the facility as soon as possible to assist LPA. LPA did not observe a designated facility representative LIC 308 with an active Administrative certificate holder.

LPA observed the Accessory Dwelling Unit (ADU) in the backyard to be locked and made inaccessible to residents and staff. LPA inquired about opening the ADU for inspection and was denied access. LPA was informed that staff do not have keys due to it being used by the AD. LPA informed staff that the entire facility is under inspection to licensing and needs to be accessible. LPA was unable to clear the Plan of Correction that was cited on October 22, 2025, for regulation 87204(a) due to not having access and observing the inside of the ADU. An immediate civil penalty was assessed at the time of the visit.

Continue on 809-C

NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: Hanna Gough
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2025
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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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: 10/29/2025
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Based on today’s observations citations and immediate civil penalties are being issued per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report along with LIC 809-D, immediate civil penalties 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: 10/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 10/29/2025 05:04 PM - It Cannot Be Edited


Created By: Hanna Gough On 10/29/2025 at 04:27 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: 10/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/30/2025
Section Cited
CCR
87755(a)

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87755 (a) Inspection Authority of the Licensing Agency
(a) Any duly authorized officer, employee or agent of the licensing agency may, upon proper identification and upon stating the purpose of his/her visit, enter
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Licensee stated they will give staff a key for staff to access ADU upon licensings arrival. Licensee stated they will review regulations and send a statement of understanding to LPA by POC due date.
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and inspect the entire premise of any place providing services at any time... This requirement was not met as evidence by: LPA was denied access to the ADU in the facility backyard. This poses an immediate health, safety and personal rights risk to residents in care.
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Type A
10/30/2025
Section Cited
CCR87405(a)

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87405(a) Administrator - Qualifications and Duties ...When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible...
This requirement was not met as evidence by:
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Licensee stated they will fill out a LIC 308 and send to LPA by POC due date.
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LPA did not observe a LIC308 and AD informed LPA they will not be coming to the facility and did not have anyone to send other than the caregivers that had just left. This poses an immediate health, safety and personal rights 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.
Armando J Lucero
NAME OF LICENSING PROGRAM MANAGER:
Hanna Gough
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/29/2025 05:04 PM - It Cannot Be Edited


Created By: Hanna Gough On 10/29/2025 at 04:35 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: 10/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/30/2025
Section Cited
CCR
87355(e)(2)

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87355 (e)(2) Criminal Record Clearance
Obtain a California clearance or a criminal record exemption as required by the Department...
This is requirement is not met as evidence by: LPA observed staff at the
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LPA observed the staff leave the premises.
Immediate civil penalty was assessed.
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facility that was not background cleared and associated to the facility. This poses an immediate health safety or personal rights 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.
Armando J Lucero
NAME OF LICENSING PROGRAM MANAGER:
Hanna Gough
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2025


LIC809 (FAS) - (06/04)
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