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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 455002633
Report Date: 11/20/2024
Date Signed: 11/20/2024 10:40:24 AM

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
08/08/2024 and conducted by Evaluator Ivan Avila
COMPLAINT CONTROL NUMBER: 59-AS-20240808154742
FACILITY NAME:A TOUCH OF HEAVENFACILITY NUMBER:
455002633
ADMINISTRATOR:PRATHER, SARAHFACILITY TYPE:
740
ADDRESS:760 KERRYJEN CTTELEPHONE:
(530) 226-5052
CITY:REDDINGSTATE: CAZIP CODE:
96002
CAPACITY:28CENSUS: 17DATE:
11/20/2024
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Tricia CockrumTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Resident fell multiple times due to staff neglect resulting in injuries
INVESTIGATION FINDINGS:
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On 11/20/2024 Licensing Program Analyst (LPA) Ivan Avila conducted an unannounced complaint investigation visit regarding the above allegation directed by the Department. LPA met with Tricia Cockrum and explained the purpose of the visit.
During the investigation process, interviews and a records review were initiated.
LPA investigated the allegation, “Resident fell multiple times due to staff neglect resulting in injuries.” Based on record review and interviews conducted, R1 sustained multiple falls at the facility. R1 had also sustained some minor injuries. R1 had fallen from her bed after staff forgot to adjust the resident’s bedrails causing R1 to fall from the bed.
Based on LPAs observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, and the California Health and Safety Code are cited on the attached LIC9099-D.
An exit interview was conducted, and a copy of the report and appeal rights were provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Ivan AvilaTELEPHONE: (559) 974-4915
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024
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 3
Control Number 59-AS-20240808154742
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: A TOUCH OF HEAVEN
FACILITY NUMBER: 455002633
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/22/2024
Section Cited
CCR
87466
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87466 The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. This requirement is not met as evidence by:
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Facility will complete a statement of understanding regarding regulation 87466. Facility will submit statement of understanding via email to LPA by POC due date of 11/22/2024.
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Based on interviews and record review, the licensee did not comply with the section cited above as R1 required frequent observation after multiple falls that was not provided resulting in injuries, which posses an immediate Health, Safety, and/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.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Ivan AvilaTELEPHONE: (559) 974-4915
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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
08/08/2024 and conducted by Evaluator Ivan Avila
COMPLAINT CONTROL NUMBER: 59-AS-20240808154742

FACILITY NAME:A TOUCH OF HEAVENFACILITY NUMBER:
455002633
ADMINISTRATOR:PRATHER, SARAHFACILITY TYPE:
740
ADDRESS:760 KERRYJEN CTTELEPHONE:
(530) 226-5052
CITY:REDDINGSTATE: CAZIP CODE:
96002
CAPACITY:28CENSUS: 17DATE:
11/20/2024
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Tricia CockrumTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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9
Staff did not safeguard resident's personal belongings
INVESTIGATION FINDINGS:
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On 11/20/2024 Licensing Program Analyst (LPA) Ivan Avila conducted an unannounced complaint investigation visit regarding the above allegation directed by the Department. LPA met with Tricia Cockrum and explained the purpose of the visit.
During the investigation process, interviews and a records review were initiated.
LPA investigated the allegation, “Staff did not safeguard resident’s personal belongings.” Based on record review and interviews conducted, R1 had items missing but it was determined that they had been misplaced and then returned to R1. There had been instances where another resident would grab R1s stuff and move them to a different room and staff would find them and put them back. LPA also observed R1s supplies of briefs that were kept in a storage area that were said to have been missing.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBTANTIATED.
An exit interview was conducted, and a copy of the report and appeal rights was provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Ivan AvilaTELEPHONE: (559) 974-4915
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3