Celestial Garden

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Hanna Gough made an unannounced visit to the facility to conduct a case management visit. LPA was greeted and granted entry by staff. LPA met with Administrator (AD) Diane Nguyen and discussed the purpose of the visit. LPA gave a citation during the annual inspection on October 22, 2025, for section 87204(a) that has been dismissed. During the visit LPA cited the proper section under section 87293 Fire Safety as stated in the appeal letter given to AD. LPA observed the ADU being used as storage only and the citation was cleared at the time of the inspection. Based on today's visit California Code of Regulations are being cited on the attached LIC9099D and civil penalty assessed. An exit interview was conducted and a copy of this report, clearance letter, LIC9099D, LIC421IM and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Mar 10, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87203 · Plan of correction due date: Mar 10, 2026

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 was not met as evidence by: LPA observed the ADU in the backyard being used as living quarters with a bed, clothes and food observed inside without being fire cleared. This poses a potential health and safety risk.the state’s words, verbatim · CDSS document, Mar 10, 2026

Plan of correction: Licensee stored the bed upright and removed bed frame, food and personal items for the ADU to be used as storage only. LPA cleared the citation at the time of the visit. *Civil Penalty assessed

Type of visit: POC

Licensing Program Analyst (LPA) Hanna Gough made an unannounced visit to the facility to conduct a plan of correction visit for deficiencies issued during the annual inspection issued on October 22, 2025. LPA was greeted and granted entry by staff. Caregiver August Rebollar called Administrator Diane Nguyen and informed her that LPA was at the facility. Administrator granted Caregiver permission to assist LPA during the visit and was available by phone. LPA toured the facility and tested the water in the resident restroom to be at 106.5 degrees Fahrenheit thus clearing the citation 87303(e)(2) stating that water needs to be between 105 and 120 degrees Fahrenheit has been corrected. LPA reviewed staff files and observed them to be complete with all regulatory requirements thus clearing the citation 87412(a) stating that staff files will be maintained on each employee at the facility has been corrected. LPA reviewed resident files and observed medical assessments with all current residents in care thus clearing the citation 87458(c)(1) stating that a physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination has been corrected. LPA reviewed documentation of a fire drill conducted with staff on November 1, 2025 clearing the citation 1569.695(c) stating that a disaster drill is to be conducted quarterly has been corrected. Based on today's visit all Type B citation plan of corrections from October 22, 2025, have been fulfilled by the assigned plan of correction due date of November 5, 2025 and no citations were noted per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Nov 7, 2025

Type of visit: POC

Licensing Program Analyst (LPA) Hanna Gough made an unannounced visit for the purpose of conducting a Plan of Correction inspection for deficiencies issued on October 22, 2025, and October 29, 2025, during the annual inspection and during a case management deficiencies visit. LPA was greeted and granted entry by staff. LPA met with Administrator (AD) Diane Nguyen and discussed the purpose of the visit. LPA observed the inside of the accessory dwelling unit (ADU) and observed the mattress to be stored in the garage separate from the bed frame and the appliances that are being stored in the ADU are unplugged. LPA observed the ADU being used as a storage space. The plan of correction for the Type A deficiencies CCR 87755(a) and 87204(a) have been cleared. LPA observed a LIC308 Designation of Facility Responsibility filled out with the delegating authority on behalf of the facility licensee. The plan of correction for the Type A deficiency CCR 87405(a) has been cleared. Based on today’s observations no deficiencies are being noted per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Oct 31, 2025

Type of visit: POC

Licensing Program Analyst (LPA) Hanna Gough made an unannounced visit for the purpose of conducting a Plan of Correction inspection for a deficiney issued on October 22, 2025, during the annual inspection. LPA was greeted and granted entry by staff. LPA met with Caregiver August Rebollar and discussed the purpose of the visit. LPA observed letters for Resident #1 and Resident #2 stating they agree to discontinue use of their over the counter medications and supplements until physicians orders are obtained. LPA observed the medications have been removed from the residents medication boxes. LPA observed the Medication Administration Record to have the medications discontinued on October 22, 2025. Based on today's observations the Plan of Correction has been fulfilled by the assigned Plan of Correction due date of October 23, 2025, thus clearing the Type A deficiency CCR 87465(c)(1). An exit interview was conducted with August Rebollar and a copy of this report was left at the facility along with POC clearance letter.the state’s words, verbatim · CDSS document, Oct 29, 2025

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Hanna Gough arrived at the facility to conduct a Case Management Deficiencies inspection. LPA was greeted and granted entry by staff. LPA met with Caregiver August Rebollar and discussed the purpose of the visit. LPA was informed that the Administrator (AD) will not be coming to the facility and that the caregivers were on their way to the doctors and could not assist LPA during the visit. LPA inquired about the one caregiver at the facility. Staff #1 (S1) informed LPA that they were hired through an agency and have only been at the facility for one day. S1 informed LPA that they were not given instructions before being left alone with the residents so they did not know how to assist LPA. LPA did not observe that S1 was background cleared and associated to the facility. An immediate civil penalty was assessed at the time of the visit. LPA waited for staff to return to the facility and observed S1 leave the facility property. The AD informed LPA that they cannot assist at the facility and that they do not have anyone that they can send over to help. AD informed LPA that they will call the caregivers and have them return to the facility as soon as possible to assist LPA. LPA did not observe a designated facility representative LIC 308 with an active Administrative certificate holder. LPA observed the Accessory Dwelling Unit (ADU) in the backyard to be locked and made inaccessible to residents and staff. LPA inquired about opening the ADU for inspection and was denied access. LPA was informed that staff do not have keys due to it being used by the AD. LPA informed staff that the entire facility is under inspection to licensing and needs to be accessible. LPA was unable to clear the Plan of Correction that was cited on October 22, 2025, for regulation 87204(a) due to not having access and observing the inside of the ADU. An immediate civil penalty was assessed at the time of the visit. Continue on 809-C Based on today’s observations citations and immediate civil penalties are being issued per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report along with LIC 809-D, immediate civil penalties and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Oct 29, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87755(a) · Plan of correction due date: Oct 30, 2025

87755 (a) Inspection Authority of the Licensing Agency (a) Any duly authorized officer, employee or agent of the licensing agency may, upon proper identification and upon stating the purpose of his/her visit, enter and inspect the entire premise of any place providing services at any time... This requirement was not met as evidence by: LPA was denied access to the ADU in the facility backyard. This poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 29, 2025

Plan of correction: Licensee stated they will give staff a key for staff to access ADU upon licensings arrival. Licensee stated they will review regulations and send a statement of understanding to LPA by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87405(a) · Plan of correction due date: Oct 30, 2025

87405(a) Administrator - Qualifications and Duties ...When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible... This requirement was not met as evidence by: LPA did not observe a LIC308 and AD informed LPA they will not be coming to the facility and did not have anyone to send other than the caregivers that had just left. This poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 29, 2025

Plan of correction: Licensee stated they will fill out a LIC 308 and send to LPA by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Oct 30, 2025

87355 (e)(2) Criminal Record Clearance Obtain a California clearance or a criminal record exemption as required by the Department... This is requirement is not met as evidence by: LPA observed staff at the facility that was not background cleared and associated to the facility. This poses an immediate health safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 29, 2025

Plan of correction: LPA observed the staff leave the premises. Immediate civil penalty was assessed.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Hanna Gough arrived at the facility to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA met with Caregiver August Rebollar and discussed the purpose of the visit. Caregiver informed LPA that the Administrator is currently flying back to California and will not be able to come to the facility for the visit. The facility currently has six residents in care. The facility is a one story home with six resident bedrooms, one staff bedroom, six bathrooms, kitchen, two living rooms, attached garage and backyard. Facility appears clean, safe and sanitary. LPA observed the resident bedrooms to have the required components and furnishings. LPA observed a fresh supply of clean linens in the closet by the front door. LPA observed the resident restrooms to have toilet paper, paper towels and textured shower flooring. LPA tested the water to be between 123.2-124.0 degrees Fahrenheit. LPA observed Caregiver turn the water heater down during the inspection. LPA observed the kitchen to be clean and free of vermin. LPA observed a two day perishable and seven day non perishable food supply on hand. LPA observed the toxins to be locked under the kitchen sink. LPA observed the knives to be locked in a drawer next to the kitchen sink. LPA observed the centrally stored medication to be in a locked cabinet located in the dining room. LPA observed the garage to store an extra food supply and toxins and chemicals on separate shelves. LPA observed the garage to be locked and made inaccessible to residents in care. LPA observed the backyard to be free of debris and obstructions. LPA observed an accessory dwelling unit (ADU) that is being used as a staff bedroom that was not observed on the fire clearance. A civil penalty was assessed at the time of the inspection. LPA observed a shaded seating area in the backyard for resident use. LPA and Caregiver tested the carbon monoxide and smoke detectors and they were found to be operational. Continue on 809-C LPA reviewed staff files and 2 of 2 staff files were incomplete. LPA observed resident files and 3 of 6 residents did not have a medical assessment for review and 5 of 6 residents did not have an updated needs and services plan. LPA did not review an updated disaster plan. LPA reviewed resident medications and 2 of 6 residents have medications without prescriptions. All staff are background cleared and associated to the facility. Based on today’s observations a civil penalty and citations are being assessed per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report, LIC 809D, 858, 859, technical violation, civil penalty, and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Oct 22, 2025

The state marks this report as 7 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

Type of visit: Prelicensing

Licensing Program Analysts (LPAs) Rose Ruppert and Fred Arias conducted an announced follow-up pre-licensing visit at 3:25 PM. LPAs were greeted and granted by staff and met with Diane Nguyen, Administrator/ Prospective Licensee (LE) and explained the purpose of our visit. LPAs toured the facility and inspected the following areas that needed to be corrected for licensure. All non-ambulatory room exits had working auditory alarms. LPA Arias measured six of six bathroom temperatures and all bathrooms measured below 120 degrees Fahrenheit. Shower grab bars were installed in bathrooms #2 and #3. LE purchased a new stove and LPA Ruppert confirmed all stove burners self ignite. The handle to the exit sliding glass door is repaired. LPAs inspected the exterior and confirmed the Additional Dwelling Unit (ADU) was used as storage. All furniture was disassembled and stored. LPA Ruppert recommended to LE to add any additional family members to Guardian if they will be spending more than ten hours a week at the facility. LPAs conducted the Component Three Orientation with LE. LE was notified that the final application approval will be issued by the Centralized Applications Bureau in Sacramento. An exit interview was conducted and a copy of this report was provided to Licensee.the state’s words, verbatim · CDSS document, Nov 18, 2024

Type of visit: Prelicensing

Licensing Program Analysts (LPAs) Nancy Guillen, Brandon Lopez and Rose Ruppert made an announced visit to the facility for the purpose of conducting a pre-licensing inspection. LPAs met with Administrator (AD) Diane Nguyen and Licensee Khanh Ton. An application to operate a Residential Care Facility for the Elderly (RCFE) for six non- ambulatory residents with six residents approved for hospice was received by Community Care Licensing (CCL) on February 13, 2024. The facility is a one-story house with six resident bedrooms, one staff bedroom, six bathrooms, two living rooms a,dining room, kitchen and an unattached staff room in the backyard. LPAs observed the See Something, Say Something poster (PUB 475) in the facility mounted on the wall near the bulletin boards in the second living area. There is a backyard with an exit gate on each side of the house. There is a shaded seating area and LPAs did not observe any obstacles or hazards in the backyard. At 1:30 PM LPAs toured the facility and observed each of the six private residents bedrooms had the required furnishings. Bed rail orders were on file and each room had a lamp, chest of drawers, chairs and linens. LPAs tested hot water temperatures in six of six resident bathrooms. The hot water temperatures measured between 116.7 to 127.4 degrees Fahrenheit. The following faucets measured as follows: Bathroom #1 was 124.5 degrees, Toilet #1 was 121.2 degrees, Toilet #3 was 125.9 degrees and Toilet #2 was 127.4 degrees Fahrenheit. Bathroom #2 is a staff bathroom and does not require grab bars in the shower and Bathroom #3 does not have a grab bar in the shower and is in a resident bedroom. LPAs observed Bedroom #7 did not have an auditory exit alarm. The sliding glass door handle exit into the backyard was in disrepair. There are push pins on the wall next to the residents bed in Bedroom #1 which Administrator immediately removed. LPAs observed razors in three of six bathrooms and asked licensee to remove them and store them in a secured area. (Continued on LIC 809-C) Continued from LIC 809) LPAs inspected the physical plant and observed the centralized smoke alarm and carbon monoxide detector were operational. The fire extinguishers were charged and were serviced on February 15, 2024. LPAs inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. LPAs observed pantry and canned goods expiration dates and all were not expired. LPAs observed sharps and knives were in a locked drawer and chemicals were secured under the sink. The medication storage and resident files were locked and a First Aid kit was observed with the required elements including a First Aid Manual. LPAs confirmed that administrator has a current administrator certificate which expires on August 19, 2026. LPA will re-schedule a follow-up pre-licensing visit for this facility. Administrator and Licensee will adjust the hot water temperatures in three of six bathrooms to be within 105 -120 degrees Fahrenheit. Administrator will place grab bars in bathroom #3. An alarm was installed in Bedroom #7's exit door during our visit. An exit interview was conducted and a copy of this report was provided to the Administrator.the state’s words, verbatim · CDSS document, Oct 28, 2024

Type of visit: Office

: Component II completion: Successful Facility Type: RCFE Application Type: Initial Capacity: 6 Census (if any clients in care): 0 COMP II Participants: Diane Nguyen (applicant/licensee, administrator) Interview Method: Microsoft teams On 9/24/2024, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Sep 24, 2024