315920266-8-14-2025-59-AS-KHIA-DKK2LL-20250814172943

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 315920266
Report Date: 08/14/2025
Date Signed: 08/14/2025 05:30:22 PM

Document Has Been Signed on 08/14/2025 05:30 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:	HEAVENBLESSED		FACILITY NUMBER:	315920266
ADMINISTRATOR/ DIRECTOR:	GRAY, PAUNITTA		FACILITY TYPE:	740
ADDRESS:	1220 LIVE OAK LANE		TELEPHONE:	(530) 718-0932
CITY:	AUBURN	STATE: CA	ZIP CODE:	95603
CAPACITY: 6		CENSUS: 2	DATE:	08/14/2025
TYPE OF VISIT:	Case Management - Legal/Non-compliance	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	03:30 PM
MET WITH:	Paunitta Gray		TIME VISIT/ INSPECTION COMPLETED:	05:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	A Non-Compliance conference was conducted today online using Microsoft Teams Meeting. The purpose of this meeting is to discuss two substantiated complaints and citations issued. Present in the meeting is Regional Manager Alycia Berryman, Licensing Program Manager Troy Ordonez, Licensing Program Manager Laura Munoz, and Licensing Program Analyst Kerry Hiratsuka. Licensee/Administrator Paunitta Gray represented the facility. The purpose of this non-compliance conference process was explained during this meeting. The facility had citations issued because of absence of supervision which was the result of two minor children left alone with two residents with no staff at the facility; a caregiver working with no criminal record clearance and no training while licensee was out of the country; the licensee’s husband not having criminal record clearance and working while the licensee was out of the country; not seeking medical attention for a resident who fell and complained of pain after the fall; not enough staff supervision to meet the resident needs due to resident falling and the caregiver unable to assist resident off the floor and that caregiver had to call the licensee’s husband to assist picking up the resident; the facility air conditioner broken while the licensee was out of the country and no plans were put into place to ensure the residents had coverage to meet their needs.

NAME OF LICENSING PROGRAM MANAGER: Troy Ordonez
NAME OF LICENSING PROGRAM ANALYST: Kerry Hiratsuka
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/14/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2025

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: 08/14/2025

NARRATIVE

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·Issues discussed during the meeting were:
• Leaving the facility with minor children and two residents without staff.
• Staff working without criminal record clearance
• Staffing issues and training
• Administrators lack Oversight.
• When to seek medical attention during an emergency or non-emergency.
• Facility failed to seek medical attention.
• Licensee/Administrator accountability

· The facility has stated they will do the following to achieve continued and substantial compliance by August 20, 2025
• Plan for staffing coverage to ensure there is staff present all the time
• Staff have criminal record clearance and associated prior to working.
• To ensure staff have all required training prior to working
• Submit a written statement of understanding about when to call 911 and when to reach out to the physician, advice nurse, or an after-hours medical professional.
• Submit a written statement of understanding that Licensee is to submit in writing to Community Care Licensing Division prior to accepting residents and what their conditions are.
• Submit the LIC 500 facility personnel or staff schedule for the months June through September 2025.
• Submit a plan for emergencies.

No deficiencies cited.

LPA is going to send a copy of this report to Licensee and Licensee is to email or mail a signed copy back to LPA.

NAME OF LICENSING PROGRAM MANAGER: Troy Ordonez
NAME OF LICENSING PROGRAM ANALYST: Kerry Hiratsuka
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/14/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2025

LIC809 (FAS) - (06/04)

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