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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006084
Report Date: 02/14/2024
Date Signed: 02/14/2024 05:28:46 PM


Document Has Been Signed on 02/14/2024 05:28 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:
306006084
ADMINISTRATOR:ANALIE FRANCISCOFACILITY TYPE:
740
ADDRESS:429 S SHIELDS DRIVETELEPHONE:
(714) 580-2338
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:6CENSUS: 5DATE:
02/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Administrator, Mary Jean AlvaradoTIME COMPLETED:
05:50 PM
NARRATIVE
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On 2/14/2024 at 8:45 AM, Licensing Program Analyst (LPA) Jenifer Tirre and Licensing Program Manager Lourdes Montoya conducted an unannounced required visit using the CARE Inspection Tool. LPA and LPM were greeted by Mercedes Pasion and granted entry after stating the purpose of the visit. Administrator Mary Jane Alvarado arrived later and joined the visit.

The facility is licensed for six (6) non-ambulatory residents with approved hospice waiver for three (3) residents. Currently, there is one (1) Hospice resident present during today’s visit.

This is a single story with a two-car garage facility. The facility has seven bedrooms, three full bathrooms and three half bathrooms.

At around 9:05 AM, LPA conducted a tour of the physical plant accompanied by Administrator Alvarado, and the following was observed: There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the client's personal belongings was observed. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured at 146.8 degrees F in a resident’s (R3) ensuite bathroom and 147.5 degrees F. in the residents’ common bathroom. A comfortable temperature of 75 degrees F. was maintained in the facility.



LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. A review of the Medication Records Administration (MAR) was conducted.

CONTINUED ON 809C
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 401-6844
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2024
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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Document Has Been Signed on 02/14/2024 05:28 PM - It Cannot Be Edited

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: 306006084

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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, LPA observed Staff 1 is missing LIC 503 Health Screening, employee rights, and TB screening. Staff 2 is missing employee rights and TB screening. Staff 3 is missing education, LIC 503 health screening and TB screening. The licensee did not comply with the section cited above in which poses a potential health, safety and or personal rights risk to persons in care.
POC Due Date: 02/28/2024
Plan of Correction
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Administrator agreed to complete personnel records for S1, S2 and S3. Administrator will submit proof of correction to department via email by POC due date 2/28/24.
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation,LPA observed expired cans of green beans. The licensee did not comply with the section cited above which poses a potential health, safety and or personal rights risk to persons in care.
POC Due Date: 02/28/2024
Plan of Correction
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Administrator agreed to review food products and discard expired items. Administrator will review regulation and provide in service training to staff and provide proof of training. Administrator will submit proof of correction to department via email by POC due date 2/28/24.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 401-6844
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/14/2024 05:28 PM - It Cannot Be Edited

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: 306006084

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)(A)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. (A) When any medical assessment, appraisal, or observation indicates that the resident's dementia care needs have changed, corresponding changes shall be made in the care and supervision provided to that resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, LPA observed that Resident 3's Physicians report is not updated, Physician's report is dated 1/25/23 and apprasial was dated 1/27/22. The licensee did not comply with the section cited above which poses a potential health, safety and or personal rights risk to persons in care.
POC Due Date: 02/28/2024
Plan of Correction
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Administrator agreed to update R3's physicians report and Needs & apprasial. Administrator to provide proof of correction to department via email by POC due date 2/28/24.
Type B
Section Cited
CCR
87203
87203 Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation LPA observed two fire extinguishers to be expired with dates of 4/5/21 and 10/15/21 the licensee did not comply with the section cited above which poses a potential health, safety and or personal rights risk to persons in care.
POC Due Date: 02/21/2024
Plan of Correction
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Administrator agreed to update fire extinguishers to be in compliance. Administrator to provide copy of invoice and photo of updated fire extinguisher tags to department via email by POC due date 2/21/24.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 401-6844
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2024
LIC809 (FAS) - (06/04)
Page: 3 of 6


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: 306006084
VISIT DATE: 02/14/2024
NARRATIVE
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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

LPA observed First Aid Kit was maintained. A working landline phone, (714) 820-6161, is operational. The last fire drill was conducted on 11/16/23. The facility had operational smoke and carbon monoxide in bedrooms and common areas. The facility has current liability insurance on file effective 2/10/2024 – 2/10/2025. The facility is current on Community Care Licensing annual dues.

A review of three residents (R1-R3) service files and three staff (S1-S3) personnel files was conducted. The facility has the current administrator's certification on file for Mary Jane Alvarado # 6040876740 - Expiration 6/9/2024.

Based on the observations made during today's visit, deficiencies are being cited as per the Title 22 Division 6 Chapter 2 of the California Code of Regulations.

An exit interview was conducted, and a copy of this report and appeal rights were provided to Mary Jane Alvarado.

SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 401-6844
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024
LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 02/14/2024 05:28 PM - It Cannot Be Edited

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: 306006084

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(4)
Incidental Medical and Dental 87465(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review LPA observed one medication Docusate sodium 100mg for R3 and Pradaxa 110mg for R1 not labeled. The licensee did not comply with the section cited above which poses a potential health, safety and or personal rights risk to persons in care.
POC Due Date: 02/28/2024
Plan of Correction
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Administrator agreed to provide labels for R1 and R3's medication and ensure all OTC medications that are centrally stored are labeled.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 401-6844
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2024
LIC809 (FAS) - (06/04)
Page: 5 of 6


Document Has Been Signed on 02/14/2024 05:28 PM - It Cannot Be Edited

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: 306006084

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
87303 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 controlls 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 degree C) and not more than 120 degree F (49 degree C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation LPA measured water temperature in multiple bathrooms. LPA observed water temperature in restrooms to measure between 146.8 and 147.5. The licensee did not comply with the section cited above which poses an immediate health, safety and or personal rights risk to persons in care.
POC Due Date: 02/14/2024
Plan of Correction
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During visit Administrator lowered water temperature for water tank. Water was adjusted at time of visit and temperature was measured in bathroom faucets to 113. 0 and 111.0 deficiency was corrected during visit and in compliance.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 401-6844
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2024
LIC809 (FAS) - (06/04)
Page: 6 of 6