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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001017
Report Date: 09/28/2021
Date Signed: 09/29/2021 08:52:29 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:CELESTIAL GARDENFACILITY NUMBER:
306001017
ADMINISTRATOR:ELISABETHA & PAVEL JIVANFACILITY TYPE:
740
ADDRESS:429 S. SHIELDS DR.TELEPHONE:
(714) 761-5332
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:6CENSUS: 4DATE:
09/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Elisabetha Jivan, AdministratorTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Kathrina Chin conducted an unannounced required annual inspection in this facility. LPA met with Elisabetha Jivan, Administrator and stated the purpose of this visit.

The facility is a single structure and licensed for six non-ambulatory.

LPA Chin was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. Facility had four residents in care and three staff members on the floor. LPA toured the interior and exterior portions of the facility. There were one private and three shared rooms. Rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke, carbon monoxide and auditory exit alarms were tested to be operational. Bathrooms were observed to be in good repair; and provided with grab bars and non-skid floor mats. Hot water was measured at 110.7 degrees Fahrenheit. Facility met the minimum two-day perishable and seven-day non-perishable food stock requirements. Medications, cleaning supplies and sharp items were inaccessible to residents in care. Fire extinguisher was mounted and charged. For the exterior portion, facility had patio furniture in good repair, and grounds were free of tripping hazards. Side exit door was self-closing and self-latching.

LPA Chin reviewed the COVID 19 mitigation plan of the facility.

For this visit, the facility was observed to be in substantial compliance with Title 22 Division 6 of the California Code of Regulations.

LPA Chin conducted an exit interview with Elisabetha Jivan, AD; and copy of this report was left in the facility.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina ChinTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021
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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