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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315920266
Report Date: 02/05/2025
Date Signed: 02/05/2025 02:56:50 PM

Document Has Been Signed on 02/05/2025 02:56 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:
02/05/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Paunitta Gray, ApplicantTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 2/5/2025 LPA Tryon met with Paunitta Gray at the facility to complete a prelicensing inspection.
There are currently 2 residents living at the facility.
LPA toured the house including common areas, kitchen, food storage, equipment; bedrooms, bathrooms, storage, laundry area, yard/patio.
The house is clean, nicely furnished and in good condition. Smoke detectors and carbon monoxide detectors installed. Facility has night lights in hallway and rooms. Bedrooms are appropriately furnished with required furniture and lighting. Food supplies are adequate to meet the requirement of 2 days perishable and 7 days non-perishable. Food is stored appropriately. Facility has dishes, utensils, kitchen equipment that is in good condition. Hot water temperature maintained at appropriate range. Plumbing fixtures in good condition and functional. Cleaners, sharp items and other potentially harmful items are secured, and chemicals are stored separately from food. Medications are centrally stored, logged and locked. There is a small refrigerator available if needed for storage of refrigerated medication.
Yard is spacious and plenty of shade available. No hazards noted. There is a metal ramp to the front door that is in good condition.
The facility maintains client files with required documents and information, as well as staff files including training, etc.
At this time, the facility appears to be in substantial compliance with regulations and requirements.

LPA also reviewed the RCFE Component III Orientation with the applicant. Component III Orientation is complete.

LPA will notify the Central Application worker that the prelicensing visit and Orientation Comp III are complete; and no deficiencies or corrections were noted at the facility.

Exit interview conducted.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE: DATE: 02/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/05/2025
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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