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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 315920266
Report Date: 08/19/2025
Date Signed: 08/19/2025 05:03:21 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
06/23/2025 and conducted by Evaluator Kerry Hiratsuka
COMPLAINT CONTROL NUMBER: 59-AS-20250623101544
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: 1DATE:
08/19/2025
UNANNOUNCEDTIME BEGAN:
03:25 PM
MET WITH:Paunitta GrayTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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1. Observation of the Resident- Facility did not observe and respond to the resident’s cognitive and behavioral needs.
2. Reappraisal-Facility did not update the resident’s care plan after significant changes in condition.
3. Staff Training Requirements-Facility did not provide training for staff to care for residents with memory loss and swallowing issues.
INVESTIGATION FINDINGS:
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On August 19, 2025, Licensing Program Analyst (LPA) Hiratsuka spoke to licensee to deliver complaint findings for the above allegation.

1. After reviewing two of two resident files, there are no pre-appraisals or needs and services plans conducted of the residents indicating the level of care and supervision they require. Because there is no documentation of what the level of care and supervision the residents require the allegation are substantiated.


Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025
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 5
Control Number 59-AS-20250623101544
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: 08/19/2025
NARRATIVE
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2. After reviewing one of two resident files, there was no reappraisal conducted of the resident indicating the level of care and supervision they required after the resident’s home health contract ended. The ending of home health signifies there was a change in the resident's condition. Because no reappraisal was conducted there is no documentation of the level care and supervision the resident requires. The allegation is substantiated.

3. Based on staff record review, the staff did not have training required by Community Care Licensing Division.

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: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 59-AS-20250623101544
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: 08/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/05/2025
Section Cited
CCR
87457(a)
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Pre-Admission Appraisal Prior to admission, the prospective resident and his/her responsible person, if any, shall be interviewed by the licensee or the employee responsible for facility admissions. Based on record review, the licensee did not comply with the section cited above two out of two residents do not have pre-admission appraisals,
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By 09/05/2025, the licensee shall submit a written plan of correction on how they shall ensure residents and potential residents have pre-appraisals prior to moving in to ensure residents' level of care and supervision are met.
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which poses a possible health, safety or personal rights risk to residents in care.Based on record review, the licensee did not comply with the section cited above two out of two residents do not have pre-admission appraisals, which poses a possible health, safety or personal rights risk to persons in care.
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Type B
09/05/2025
Section Cited
CCR
87463(a)
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Reappraisals The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to
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By 09/05/2025, the licensee shall submit a written plan of correction on how they shall ensure residents how have a change in level of care get reappraisals done to ensure their level of care and supervision are met.
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keep the appraisal accurate. Based on record review, the licensee did not comply with the section cited above one out of two residents do not have reappraisals, which poses a possible health, safety or personal rights risk to persons 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: 08/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
06/23/2025 and conducted by Evaluator Kerry Hiratsuka
COMPLAINT CONTROL NUMBER: 59-AS-20250623101544

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: 1DATE:
08/19/2025
UNANNOUNCEDTIME BEGAN:
03:25 PM
MET WITH:Paunitta GrayTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Incidental Medical and Dental Care-Staff did not follow appropriate care for a resident with swallowing difficulties.
INVESTIGATION FINDINGS:
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On August 19, 2025, Licensing Program Analyst (LPA) Hiratsuka spoke to licensee to deliver complaint findings for the above allegation.

A review of the resident files did not indicate whether a resident had swallowing difficulties. It cannot be determined if the resident had swallowing difficulties based on the absence of medical records for the resident.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 59-AS-20250623101544
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: 08/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/05/2025
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 09/05/2025, the licensee shall submit a written plan of correction on how they shall ensure staff have all the required training per Title 22 Regulations and California Health and Safety Code. The licensee shall include how they shall document the training.
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This requirement was not met as evidence based on record review which shows no training logs which indications no training was conducted, which poses a potential 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: 08/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5