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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315920266
Report Date: 06/02/2025
Date Signed: 06/02/2025 04:17:24 PM

Document Has Been Signed on 06/02/2025 04:17 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:HEAVENBLESSEDFACILITY NUMBER:
315920266
ADMINISTRATOR/
DIRECTOR:		GRAY, PAUNITTAFACILITY TYPE:
740
ADDRESS:1220 LIVE OAK LANETELEPHONE:
(530) 718-0932
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY: 6CENSUS: 2DATE:
06/02/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Lawrance GrayTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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On June 2, 2025, during the course of investigation, the department has observed multiple serious concerns about staffing, supervision, resident care, and overall facility operation during the licensee’s absence from the country. The department discovered one staff member was present and providing care, LPA spoke to a staff member on the phone, and was informed there is a third caregiver that was scheduled to show up later this afternoon. LPA observed two of the three do not have criminal record clearance. One does have criminal record clearance but is not associated to the facility. No personnel files were available for either but when a staff member arrived he showed LPA one record that is not for this facility. LPA observed the staff on duty during this visit doesn’t appear to have any training. Caregiver just admitted she has not had any training to take care of the residents. LPA couldn’t obtain access to the staff files to confirm if they staff have had any training because the administrator is not available. Resident had a fall on June 1, 2025, and facility staff didn’t seek medical attention despite the resident requesting to go. LPA observed medications are prepared seven days in advance and Title 22 regulations require medications to stay in their original container. One caregiver's first aid and CPR are expired and one does not have any.

Based on deficiencies during 10/02/2024 annual visit and complaint visit on 10/24/2024 and case management visit conducted on 10/24/2024, it shows that there is no qualified administrator operating the facility.

Deficiencies cited on the LIC 809-D, per Title 22 Regulations.

Exit interview conducted. A copy of the report has been issued. Failure to correct the deficiencies may result in Civil penalties being assessed. $1000.00 IMMEDIATE CIVIL PENALTIES ISSUED due to three staff members working with no criminal record clearance. Appeal Rights provided.
NAME OF LICENSING PROGRAM MANAGER: Troy Ordonez
NAME OF LICENSING PROGRAM ANALYST: Kerry Hiratsuka
LICENSING PROGRAM ANALYST 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.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 06/02/2025 04:17 PM - It Cannot Be Edited


Created By: Kerry Hiratsuka On 06/02/2025 at 03:20 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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
87411(g)

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Personnel Requirements – General.
Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (1) Obtain a California clearance or a criminal record exemption as required by law or Department regulations
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By 06/03/2025, Licensee shall ensure all staff who work at this facility has criminal record clearance and associated prior to working at the facility.
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This requirement was not met as evidence based on interviews and the facility staff roster that showed only the administrator has criminal record clearance, Two of the three do not have clearance and the third is not associated. which poses an immedaite health and safety risk to resident in care.
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Licensee shall submit a written statement stating how they shall ensure the staff all have criminal record clearance and association prior to working. Immediate civil penalties of $100.00 assessed.
Type A
06/03/2025
Section Cited
CCR87411(a)

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Personnel Requirements – General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs…
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By 06/03/2025, Licensee shall submit a written plan of correction how they shall ensure all staff have the required training per Title 22 Regulations both prior to working by themselves and after.
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This requirement was not met as evidence based on interviews where caregiver stated she had no training prior to working, 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.
Troy Ordonez
NAME OF LICENSING PROGRAM MANAGER:
Kerry Hiratsuka
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST 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


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/02/2025 04:17 PM - It Cannot Be Edited


Created By: Kerry Hiratsuka On 06/02/2025 at 03:27 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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
87411(c)

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Personnel Requirements – General. All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69
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By 06/03/2025, Licensee shall submit a written plan of correction how they shall ensure all staff have the required training per Title 22 Regulations both prior to working by themselves and after.
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This requirement was not met as evidence based on interviews where caregiver stated she had no training prior to working, which poses an immedaite health and safety risk to resident in care.
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Type A
06/03/2025
Section Cited
CCR87465(h)(5)

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Incidental Medical and Dental Care
The following requirements shall apply to medications which are centrally stored: Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.
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By 06/03/2025, Licensee shall come up with a written plan of correction on how they shall ensure all medication stays in their original container until being distributed.
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This requirement was not met as evidence based on observation, LPA observed medication set up for a week in a medication box labeled Monday through Friday, which poses an immediate 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.
Troy Ordonez
NAME OF LICENSING PROGRAM MANAGER:
Kerry Hiratsuka
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST 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


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/02/2025 04:17 PM - It Cannot Be Edited


Created By: Kerry Hiratsuka On 06/02/2025 at 03:31 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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
87412(f)

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Personnel Records
All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying.
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By 06/03/2025, Licensee shall submit a written plan of correction how they shall ensure staff records are available to the licensing agency upon request.
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This requirement was not met as evidence based on interviews where no one knew where the records are being kept, which poses an immediate health and safety risk to resident in care.
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Type A
06/03/2025
Section Cited
CCR87411(c)(1)

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Personnel Requirements – General. (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. Staff providing care shall receive appropriate training in first aid from
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By 06/03/2025, Licensee shall ensure all staff have first aid training prior to working.
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persons qualified by such agencies as the American Red Cross.
This requirement was not met as evidence based on interviews staff admitted they didn't have first aid, which poses an immediate 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.
Troy Ordonez
NAME OF LICENSING PROGRAM MANAGER:
Kerry Hiratsuka
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST 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


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 06/02/2025 04:17 PM - It Cannot Be Edited


Created By: Kerry Hiratsuka On 06/02/2025 at 03:37 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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
87466

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Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes ...and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as... are observed, the licensee shall ensure that such changes are
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By 06/03/2025, Licensee shall submit a written plan of correction on how they shall ensure reporting requirements are followed.
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documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not met as evidence based on interviews, the doctor was not notified of the fall, which poses an immediate health and safety risk to resident in care.
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Type A
06/03/2025
Section Cited
CCR87405(a)

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Administrator - Qualifications and Duties. All facilities shall have a qualified and currently certified administrator. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management
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By 06/03/2023, Licensee shall ensure there are at minimum a qualified substitute when the administrator is not present in the facility. The licensee shall submit a written plan of correction.
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and administration of the facility as specified in this section. This requirement was not met as evidence based on interviews and observations, there is no qualified administrator or designated substitute which poses an immediate 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.
Troy Ordonez
NAME OF LICENSING PROGRAM MANAGER:
Kerry Hiratsuka
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST 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


LIC809 (FAS) - (06/04)
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