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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002883
Report Date: 07/20/2022
Date Signed: 07/20/2022 11:44:45 AM

Document Has Been Signed on 07/20/2022 11:44 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:CELESTIAL CARE ADULT FACILITY, LLCFACILITY NUMBER:
315002883
ADMINISTRATOR:WOLFE, PATRIAFACILITY TYPE:
735
ADDRESS:4136 WEATHERVANE WAYTELEPHONE:
(530) 782-3953
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY: 4CENSUS: 0DATE:
07/20/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Staff- Charity YapdiangcoTIME COMPLETED:
12:00 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 (LPA) Talwinder Bains met with facility staff member , Charity Yapdiangco to conduct a Pre- Licensing visit. LPA followed current Covid precautions- self screened, hand sanitized and surgical mask worn. LPA was screened upon arrival.

The facility has a fire clearance for 2 non ambulatory and 2 ambulatory residents. Applicant Patria was not present during today's visit and staff member Charity told LPA Bains that she holds a current administrator certificate (#6054564735 with expiration date 12/26/23 ) and she will be the administrator for this facility and will follow up with CAB to follow required process. Another staff member Rafael Yapdiangco was also present during today's visit.



LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. There are 4 bedrooms for residents, and 1 bathroom .LPA observed facility to be properly furnished, including appropriate bedding and lighting in the facility . Bathroom was in sanitary condition and properly maintained. Facility have no staff break room on first floor and facility staff Charity and Rafael are living on second floor. Per Charity and Rafael second floor will not be used for any residence in any manner. Current facility sketch and fire clearance is given only for first floor for facility approval for ARF.

LPA checked the kitchen area for the ability to prepare and store food. LPA observed cleaning products and other toxins to be locked away. LPA observed the area used for medication to be locked and inaccessible to residents. LPA observed smoke detectors and carbon monoxide detectors at the care home to be operational. Fire extinguisher and first aid kit are maintained and ready for emergency use.

Pre-licensing passed and Component III (ARF) was completed with Charity. Facility has satisfied all requirements in accordance to Title 22, California Code of Regulations. Application is pending and LPA will forward findings to the Centralized Application Bureau (CAB) for final review and approval. CAB will further contact applicant on final status of application. A copy of this report was provided to the facility. Exit interview conducted.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE: DATE: 07/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/20/2022
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 1