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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315920266
Report Date: 06/04/2025
Date Signed: 06/04/2025 04:11:52 PM

Document Has Been Signed on 06/04/2025 04:11 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:
06/04/2025
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Elizabeth WeeksTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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During the case management visit conducted on June 4, 2025, LPA Todd Tryon, Licensing Program Manager, Troy Ordonez met with Elizabeth Weeks. During the visit, it was determined that the facility failed to correct the following deficiencies 87411(g) Personnel Requirements- 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. 87411(a) Personnel Requirements-General, Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. Based on interviews where caregiver stated she had no training prior to working, 87466-Observation of the resident-based on interviews, the doctor was not notified of the fall, 87405 (a) Administrator - Qualifications and Duties- based on interviews and observations, there is no qualified administrator or designated substitute. 87411(c) Personnel Requirements-All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training. Based on interviews where caregiver stated she had no training prior to working. 87465(h) (5) Incidental Medical and Dental Care-based on observation, LPA observed medication set up for a week in a medication box labeled Monday through Friday. 87412 (f) Personnel Records-based on interviews where no one knew where the records are being kept. 87411(c) (1) Personnel Requirements-based on interviews staff admitted they didn't have first aid by the due date of June 3, 2025. As a result, civil penalties were assessed in accordance with Title 22, California Code of Regulations.
During today’s visit, civil penalties were assessed. The staff on site was able to write a plan of correction for each of the citations, and the citations that were issued were corrected on the spot today.
In respect to the air conditioning system that was found to be non-functional, the facility is required to conduct daily temperature checks. The facility must submit daily temperature readings from various resident rooms and common areas to LPA Todd Tryon via email at john.tryon@dss.ca.gov .
NAME OF LICENSING PROGRAM MANAGER: Troy Ordonez
NAME OF LICENSING PROGRAM ANALYST: Todd Tryon
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/04/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/04/2025
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Submissions must begin on June 5,2025 and continue daily until written confirmation is received from the Department that the requirement has ended. The facility must conduct daily temperature checks in all resident rooms and common areas.
The facility has stated that repairs to the air conditioning system will occur on 6/4/2025. The facility proof of repairs to the air conditioning system to LPA Todd Tryon.
During the visit, citation was issued issued for a broken window on the front door. Deficiencies will be cited, and a Plan of Correction will be due within 24 hours. This will result in a Type A citation due to the immediate potential risk to resident health and safety.

The home will continue to do daily room temperature checks in resident rooms and common area; and send in temperature readings to LPA daily. Readings will be submitted to LPA by 7:00 p.m. each day. If reading is not submitted by 7:00 p.m. each day,

During visit the LPAs noted cameras in common areas of the facility. This is just a reminder that audio recording is not allowed in the care facility. Also, no cameras are allowed at all in the bedrooms.

Proof of clearance for Plans of Correction given; deficiency cited today as per Title 22; resources provided to staff; Appeal Rights provided, exit interview conducted. The Department will continue to make unannounced Health and Safety visits until corrections are made and air conditioner is functioning properly.
NAME OF LICENSING PROGRAM MANAGER: Troy Ordonez
NAME OF LICENSING PROGRAM ANALYST: Todd Tryon
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/04/2025 04:11 PM - It Cannot Be Edited


Created By: Todd Tryon On 06/04/2025 at 02:46 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: 06/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/05/2025
Section Cited
CCR
87303(a)

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The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This regulatoni is not met as evicenced by: Through observation LPA's noted that
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Staff member indicated that the broken glass will be removed from the door, and a temporary cover/patch will be placed in the place of the window until the home is able to replace the window, Temporary fix to be completed by 6/5/2025. Staff to submit a photo of patch by 6/5/2025; and a plan for
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the window in the front door of the house is broken, and there is loose glass with sharp edges hanging from the window, posing a potential health and safety risk.
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permanent replacement of the window.

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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:
Todd Tryon
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2025


LIC809 (FAS) - (06/04)
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