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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002633
Report Date: 06/12/2024
Date Signed: 06/12/2024 12:54:56 PM


Document Has Been Signed on 06/12/2024 12:54 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: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: 20DATE:
06/12/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Sarah PratherTIME COMPLETED:
01:00 PM
NARRATIVE
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On 06/12/2024, Licensing Program Analyst (LPA) Ivan Avila arrived unannounced at the facility to conduct a case management visit regarding an absent without leave incident report the Department received via fax on 05/29/2024. LPA met with Administrator Sarah Prather and explained the purpose of the visit.

The incident occurred on 05/29/2024 at approximately 1:30 AM when facility staff observed R1 to be missing. Facility staff conducted a search throughout the facility, and it was noted that R1 was no longer in the facility. Resident was missing for approximately 30 minutes. R1 was located later that night across the street. Based on R1's LIC 602 Physician's Report, signed on 04/03/2024, it is indicated that R1 was deemed unable to leave the facility unassisted.

LPA and Administrator discussed ensuring that staff are aware which residents can leave the facility unassisted. LPA clarified that if the LIC 602 indicates resident cannot leave unassisted then the facility is to comply. Additionally, LPA and Administrator discussed that R1 is diagnosed with a Neurocognitive Disorder, Dementia, and requires close supervision.

As a result of the incident, a deficiency is being cited per California Code of Regulations, Title 22, and California Health and Safety Code. The deficiency is documented on the LIC 809-D page.

Exit interview conducted, a copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Ivan AvilaTELEPHONE: (559) 974-4915
LICENSING EVALUATOR SIGNATURE:
DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2024
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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Document Has Been Signed on 06/12/2024 12:54 PM - It Cannot Be Edited

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: A TOUCH OF HEAVEN
FACILITY NUMBER: 455002633

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/14/2024
Section Cited
HSC
1569.312(d)

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1569.312 Every facility required to be licensed...following basic services:
(d) Being aware of the resident's general whereabouts, although the resident may travel independently in the community.
This requirement is not met as evidenced by:
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Facility will complete a statement of understanding regarding regulation 1569.312(d). Facility will submit statement of understanding to LPA by POC due date of 06/14/2024.
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Based on file review and interview, the Licensee did not comply in the section cited above as resident was observed to have left the community and is unable to leave the community unassisted, which poses an immediate health, safety, and personal rights risk to residents 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: 06/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2024
LIC809 (FAS) - (06/04)
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