<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006084
Report Date: 01/11/2022
Date Signed: 01/28/2022 11:02:34 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:
306006084
ADMINISTRATOR:ALVARADO, MARY JEANFACILITY TYPE:
740
ADDRESS:429 S SHIELDS DRIVETELEPHONE:
(714) 580-2338
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:6CENSUS: 4DATE:
01/11/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Jenny Dang, ApplicantTIME COMPLETED:
03:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst, Kathrina Chin made an announced visit for a pre-licensing evaluation. LPA met with Jenny Dang, Applicant and Mary Jean Alvarado, Administrator. The facility has seven bedrooms and three full bathrooms and three half bathrooms. This is a single story with a two car garage facility. The inspection is as follows:

A fire clearance was granted on October 20, 2021 for 6 non-ambulatory.

LPA toured the facility, interior and exterior, including all resident bedrooms. Hot water were tested in a resident bathroom and observed to be 115.7 degrees Fahrenheit. Two fire extinguishers were mounted and charged. Smoke detectors were centrally wired throughout and have been checked by the fire department. Carbon monoxide detectors are operational. There is a sufficient supply of linens. Bedrooms are appropriately furnished. There is sufficient lighting. There are non-skid mats in the showers.

There was one locked medication closet and two first aid kits. There were several locked closets for storage of toxins, cleaning equipment. PPEs are stored in the garage. All exits have auditory devices. The kitchen area was checked and there is a sufficient supply of food items. There were emergency food supplies and water in the garage. Ms. Dang stated that she will post activity calendars, theft and loss policy, residents rights, admission agreement, and emergency plans were posted. LPA observed Ombudsman and Let Us Know posters. LPA reviewed the outdoor area and with outdoor furniture with a covered patio.

A Component III was completed during the visit with Jenny Dang, Applicant. LPA reviewed Personnel Policies, Prohibited Health Conditions, Fingerprinting, Abuse Reporting Procedures, In-Service Training and Medication Procedures. (Continued LIC 9099C)
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina ChinTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: CELESTIAL GARDEN
FACILITY NUMBER: 306006084
VISIT DATE: 01/11/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
It appears that this facility meets the requirements for licensure. The license will be granted upon final review and approval from the Central Applications Bureau.

An exit interview was conducted with Jenny Dang, Applicant and a hard copy of this report was provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina ChinTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2