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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 315920266
Report Date: 08/08/2025
Date Signed: 08/08/2025 02:25:04 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
07/28/2025 and conducted by Evaluator Kevin Mknelly
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20250728103533
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:
08/08/2025
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:TIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff left residents in care unattended
INVESTIGATION FINDINGS:
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On August 8, 2025 (8/8/25), Licensing Program Analyst (LPA) Kevin Mknelly spoke to licensee to deliver complaint findings for the above allegation.

The department reviewed resident records, interagency reports and conducted extensive interviews.
LPA finds that the allegations cited above are substantiated.

On 7/28/25, the department received a report that on 7/26/25, local law enforcement was called to this home for a welfare check. Police report states that on 7/26/25, police responded to this home and found there to be two(2) elderly residents (R1 and R2) in care and the Administrator’s children in the home with no caregivers present.

Records review for the residents found R1is diagnosed as having a history of stroke, physical and cognitive deficits and to be non-ambulatory. R1 is independent with ADLs and ambulation, with diagnosis of congestive heart failure and a-fib.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2025
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-20250728103533
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: 08/08/2025
NARRATIVE
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In an interview of Administrator Paunitta Gray (S1), Ms. Gray stated that she left the home at approximately 1 PM on 7/26/25 while children and residents had no other caregivers present. Ms. Gray reported that a caregiver was to come to the facility for Ms. Gray to attend a personal appointment. Ms. Grey was reportedly informed by S2 that S2 was delayed by car trouble. Ms. Gray reported that she then returned to the home.

Ms. Gray’s absence resulted in residents in care being without staff supervision for approximately one and a half (1.5) hours.
Residents in care were unharmed during the absence of staff.

As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.

Report reviewed with licensee . Copy of this report and appeal rights provided.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 59-AS-20250728103533
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: 08/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/09/2025
Section Cited
CCR
87413(a)(1)
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Personnel - Operations (a) In each facility:
(1) When regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks.

This requirement was not met based on
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Licensee will submit a plan for normal and emergency fill in staff to the department by the POC date of 8/9/25.

An office meeting may also be scheduled.

Civil penalties applied
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statements that found residents were left unattended by facility staff.
This posed an immediate risk to residents.
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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: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3