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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 315920266
Report Date: 06/02/2025
Date Signed: 06/02/2025 04:20:28 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/02/2025 and conducted by Evaluator Kerry Hiratsuka
COMPLAINT CONTROL NUMBER: 59-AS-20250602105134
FACILITY NAME:HEAVENBLESSEDFACILITY NUMBER:
315920266
ADMINISTRATOR:GRAY, PAUNITTAFACILITY TYPE:
740
ADDRESS:1220 LIVE OAK LANETELEPHONE:
(530) 718-0932
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY:6CENSUS: 2DATE:
06/02/2025
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Lawrance GrayTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Facility too hot for residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst Kerry Hiratsuka conducted the investigation into the allegation above.

On May 30, 2025, the Department was notified that on May 30, 2025, the facility’s air conditioning was non-functional during extreme temperatures—105°F outside and 95°F inside—placing residents at immediate risk. On June 2, 2025, the Department made an unannounced health and safety visit to the facility, the department has concluded the facility’s air conditioner is not working properly. During phone interview with a staff member, the staff member claimed the air conditioner was “working,” it was not blowing cool air. An AC repair appointment was reportedly scheduled, but no evidence of repair was available. LPA confirmed the facility interior was 80°F, with a forecasted outdoor high of 86°F for Auburn, CA. The prior reported indoor temperature was 95°F. Thermometer is reading 80 degrees.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 59-AS-20250602105134
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: HEAVENBLESSED
FACILITY NUMBER: 315920266
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/03/2025
Section Cited
CCR
87303(b)
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Maintenance and Operation. A comfortable temperature for residents shall be maintained at all times.
This requirement was not met as evidence based on interviews. The husband of the administrator stated the air conditioner only blew hot air, the caregiver stated she
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By 06/03/2015, the licensee shall come up with a plan of correction to ensure the facility is maintained at a temperature that is comfortable for residents and to ensure alls staff know how to use the temperature controls.
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doesn't know how to turn on the air condtioner, and residents and a witness who stated it was very hot, which poses an immedaite health and safety risk to resident in care.
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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.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 59-AS-20250602105134
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: HEAVENBLESSED
FACILITY NUMBER: 315920266
VISIT DATE: 06/02/2025
NARRATIVE
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Based on the information gathered through interviews, LPA was able to determine that the allegation is substantiated. Therefore, the Department finds the allegation to be Substantiated. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Please see 9099-D for the deficiency cited
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3