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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340317775
Report Date: 02/24/2022
Date Signed: 02/24/2022 01:50:06 PM

Document Has Been Signed on 02/24/2022 01:50 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:CELESTIAL HOME IIFACILITY NUMBER:
340317775
ADMINISTRATOR:BURDEN,PHYLLISFACILITY TYPE:
735
ADDRESS:3350 MABEL STREETTELEPHONE:
(916) 568-7646
CITY:SACRAMENTOSTATE: CAZIP CODE:
95838
CAPACITY: 6CENSUS: 4DATE:
02/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:06 PM
MET WITH:Anna Sims & Audrey Fant TIME COMPLETED:
02:00 PM
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Licensing Program Analysts(LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual inspection on 02/24/2022 at 1:00 PM. LPA met with Anna Sims & Audrey Fant and stated the purpose of today’s visit. LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations.

LPA Martinez toured the facility with Anna Sims 02/24//2022 at 1:00 PM.

The facility has one main Covid-19 screening entry point. The facility has Covid-19 postings throughout the facility. The facility has hand sanitizer throughout the facility, and has a supply of PPE. A LIC 808 Mitigation plan has been submitted to the Department. The facility furniture is spaced 6 feet apart, and has implemented social distancing practices. The facility has a designated area for visitors.The facility is sanitary and common touched surfaces are disinfected daily. The facility smoke detectors and and carbon detectors are in good repair. New fire extinguishers have been ordered will be arriving at the facility today. The fire extinguishers were last inspected on January 2021. The exterior of the facility is clean and sanitary.

The facility is in compliance with California Code of Regulations, Title 22 and Health and Safety Code, there were no deficiencies cited at this time, however, a technical violation was given for the fire extinguishers. An exit interview was conducted, and a copy of this report was given to the facility.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2022
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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