CELESTIAL GARDEN

Official classification

Type B

Official code

87203

Regulation authority

CCR

What the official deficiency says

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.

Official 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

Deadline recorded: Mar 10, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87755(a)

Regulation authority

CCR

What the official deficiency says

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.

Official 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.

Deadline recorded: Oct 30, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87405(a)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

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

Deadline recorded: Oct 30, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

LPA observed the staff leave the premises. Immediate civil penalty was assessed.

Deadline recorded: Oct 30, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(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 controls 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 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in LPA testing the water in resident bathrooms to be between 123.2-124.9 degrees Farenheit which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/05/2025 Plan of Correction LPA observed caregiver turn the water heater down during the inspection. Licensee stated they will test the water for 5 consecutive days and send proof of water temperature to LPA by POC due date.

Official classification

Type B

Official code

87412(a)

Regulation authority

CCR

What the official deficiency says

(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 Based on record review, the licensee did not comply with the section cited above in 2 of 2 staff not having complete records on file which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/05/2025 Plan of Correction Licensee stated they will gather all documents needed and send proof of staff files completed to LPA by POC due date.

Official classification

Type B

Official code

87458(c)(1)

Regulation authority

CCR

What the official deficiency says

(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in 3 of 6 residents not having a medical assessment with TB test on file which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/05/2025 Plan of Correction Licensee stated they will obtain medical assessments for residents in care and send proof to LPA by POC due date.

Official classification

Type B

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in not conducting a quarterly disaster drill which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/05/2025 Plan of Correction Licensee stated they will conduct a disaster drill and send proof to LPA by POC due date.

Official classification

Type A

Official code

87204(a)

Regulation authority

CCR

What the official deficiency says

(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specifications of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make termporary exceptions to the approved capacity. This requirement is not met as evidenced by: Deficient Practice Statement Based on interviews, the licensee did not comply with the section cited above in LPA observing an accessory dwelling unit (ADU) in the backyard used as a staff living space for the last 2 months which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/23/2025 Plan of Correction Licensee stated they will make it a storage space and dissassemble the furniture as specified during the pre-licensing or submit for a new fire clearance and put a sign on the door of the ADU saying do not enter until it has passed inspection and send proof to LPA by POC due date.

Official classification

Type A

Official code

87465(c)(1)

Regulation authority

CCR

What the official deficiency says

(1) There is written direction from a physician, on a prescription blank, specifying the name of the resident, the name of the medication, all of the information in Section 87465(e), instructions regarding a time or circumstance (if any) when it should be discontinued, and an indication when the physician should be contacted for a medication reevaluation. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above in 2 of 6 residents having over the counter medication without a physicians order which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/23/2025 Plan of Correction Licensee stated they will obtain orders or discontinue use of medications and send proof to LPA by POC due date.