Heavenblessed

Type of visit: Office

An office meeting was held on May 18, 2026 at 11:00 am. The purpose of the meeting was to review the Stipulation and Waiver; and Order adopted by the Department on April 28, 2026. The following were in attendance: Regional Manager (RM) Harpreet Humpal, Licensing Program Manager (LPM) Laura Munoz, and Licensing Program Analyst (LPA) Cassandra Mikkelson and Respondent Paunitta Gray. LPM Munoz discussed the purpose of the meeting and read the Stipulation and Waiver, and Order in its entirety with all in attendance, including, but not limited, as follows:  Findings  Revocation of License and Administrator Certificate  Waiver of Application; Conditions of Employment  Waiver of Hearing Rights, Appeal/Modification Rights, and Claims The Respondent indicated they do not have any questions and expressed their understanding. LPM Munoz stated that a report would be drafted documenting today's discussion. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations are cited in this report. An exit interview was conducted and signature on this report acknowledges the receipt.the state’s words, verbatim · CDSS document, May 18, 2026

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Cassandra Mikkelson and Licensing Program Manager (LPM) Laura Munoz arrived unannounced at the facility. This visit is to confirm ORDERS TO INDIVIDUAL FOR IMMEDIATE EXCLUSION FROM ALL FACILITIES. LPA spoke with Licensee Paunitta Gray via phone and stated the purpose of visit. Facility understands this is an Immediate Exclusion effective February 25,2026, Licensee Paunitta Gray is excluded and cannot be allowed to work, live in, and/or have contact with clients in any residential facility licensed by the California Department of Social Services. Exit interview conducted, a copy of this report provided on this date.the state’s words, verbatim · CDSS document, Feb 25, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cassandra Mikkelson arrived unannounced to facility. Facility currently does not have any residents as ordered by the Department. No deficiencies cited during this visit.the state’s words, verbatim · CDSS document, Dec 4, 2025

Type of visit: Case Management - Legal/Non-compliance

On 08/20/2025, Sacramento North Regional Office staff, including the Regional Manager (RM) ) Alycia Rayner, two Licensing Program Managers (LPMs) Troy Ordonez, Laura Munoz and a Licensing Program Analyst (LPA) Todd Tryon, along with Local Long Term Care Ombudsman arrived unannounced at the facility to deliver a Temporary Suspension Order (TSO). The TSO shall be effective as of 5:00 PM on 08/20/2025. The Regional Office staff were met by the facility administrator, Paunitta Gray upon arrival. The RM, LPMs, and LPA conducted a tour of the facility to ensure the health and safety of resident in care. The RM reviewed the TSO paperwork with the licensee and served one resident with a copy of the TSO. The resident was also provided with information regarding the Appeal/Notice of Defense process. By 4:00 p.m., R1 was successfully relocated and no residents remained in care. An exit interview was conducted with the licensee. A copy of the report and Appeal Rights were provided. The Regional Office staff ensured that the transition process was carried out in accordance with Title 22 regulations. Collaboration with the local ombudsman supported a smooth relocation for resident, safeguarding their health, safety, and personal rights throughout the process. The Department emphasized that the TSO remains in effect and that the licensee retains the right to appeal under the Notice of Defense procedures.the state’s words, verbatim · CDSS document, Aug 20, 2025

Allegation investigated: . 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.

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 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.the state’s words, verbatim · CDSS document, Aug 19, 2025 · control 59-AS-20250623101544

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87457(a) · Plan of correction due date: Sep 5, 2025

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, 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.the state’s words, verbatim · CDSS document, Aug 19, 2025

Plan of correction: 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.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: Sep 5, 2025

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 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.the state’s words, verbatim · CDSS document, Aug 19, 2025

Plan of correction: 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.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(c) · Plan of correction due date: Sep 5, 2025

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 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.the state’s words, verbatim · CDSS document, Aug 19, 2025

Plan of correction: 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.

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Todd Tryon arrived unannounced at the facility to conduct a health and safety case management visit. LPA met with Licensee/Administrator and with Elizabeth Weeks explained the purpose of the visit. Today's visit, LPA spoke with resident R1 and gathered additional information.. Additionally, LPA and Administrator conducted a tour of the facility to ensure the health and safety of residents in care. No immediate health, safety or personal rights violation observed. No deficiencies are being cited. Exit interview conducted and copy of report was provided.the state’s words, verbatim · CDSS document, Aug 18, 2025

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a health and safety case management visit. LPA met with Administrator and explained the purpose of the visit. Today's visit, LPA gathered additional information regarding R1's primary care physician. Additionally, LPA and Administrator conducted a tour of the facility to ensure the health and safety of residents in care. No immediate health, safety or personal rights violation observed. No deficiencies are being cited. Exit interview conducted and copy of report was provided.the state’s words, verbatim · CDSS document, Aug 17, 2025

Type of visit: Case Management - Health Checks

On 8-16-25 at 6:30pm Licensing Program Analyst (LPA) Sarah Benson arrived unannounced at the facility to conduct a health and safety case management visit. LPA met with Administrator Paunitta Gray and explained the purpose of the visit. LPA and Administrator inspected the facility to check the health and safety of residents in care. Areas toured included but not limited to five (5) residents rooms, three (3) bathrooms, kitchen, common areas and the yard. LPA observed that the facility was clean and odor free. LPA Benson interviewed the resident and observed the residents medications. LPA observed the resident to be very independent. LPA Benson observed no immediate health and safety violations. No deficiencies are being cited.the state’s words, verbatim · CDSS document, Aug 16, 2025

Type of visit: Case Management - Health Checks

On August 15, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a health and safety case management visit. LPA met with Administrator and explained the purpose of the visit. LPA and Administrator conducted a tour of the facility to check the health and safety of residents in care. Areas toured included but not limited to residents rooms, bathrooms, kitchen and the common areas. LPA toured kitchen area and observed that facility has adequate food supply of two days perishable and seven days non perishable food. LPA observed that facility was clean and odor free. From the tour conducted, LPA observed no immediate health and safety violations. Today's visit, LPA and Administrator discussed staff training and certified vendors for continuing education course. LPA provided Administrator a copy of staff training health and safety codes and a list of approved vendors. No deficiencies are being cited. Exit interview conducted and copy of report left at the facility.the state’s words, verbatim · CDSS document, Aug 15, 2025

Type of visit: Case Management - Legal/Non-compliance

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. ·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.the state’s words, verbatim · CDSS document, Aug 14, 2025

Type of visit: Case Management - Other

Licensing Program Analyst Hiratsuka conducted this unannounced case management visit. LPA is removing two resident files so LPA can copy them. The files shall be returned within three business days. No deficiencies cited.the state’s words, verbatim · CDSS document, Aug 13, 2025

Allegation investigated: Staff left residents in care unattended

On August 8, 2025 (8/8/25), Licensing Program Analyst (LPA) Kevin Mknelly spoke to licensee to deliver complaint findings for the above allegation. The department reviewed resident records, interagency reports and conducted extensive interviews. LPA finds that the allegations cited above are substantiated. On 7/28/25, the department received a report that on 7/26/25, local law enforcement was called to this home for a welfare check. Police report states that on 7/26/25, police responded to this home and found there to be two(2) elderly residents (R1 and R2) in care and the Administrator’s children in the home with no caregivers present. Records review for the residents found R1is diagnosed as having a history of stroke, physical and cognitive deficits and to be non-ambulatory. R1 is independent with ADLs and ambulation, with diagnosis of congestive heart failure and a-fib. Substantiated In an interview of Administrator Paunitta Gray (S1), Ms. Gray stated that she left the home at approximately 1 PM on 7/26/25 while children and residents had no other caregivers present. Ms. Gray reported that a caregiver was to come to the facility for Ms. Gray to attend a personal appointment. Ms. Grey was reportedly informed by S2 that S2 was delayed by car trouble. Ms. Gray reported that she then returned to the home. Ms. Gray’s absence resulted in residents in care being without staff supervision for approximately one and a half (1.5) hours. Residents in care were unharmed during the absence of staff. 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.the state’s words, verbatim · CDSS document, Aug 8, 2025 · control 59-AS-20250728103533

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87413(a)(1) · Plan of correction due date: Aug 9, 2025

Personnel - Operations (a) In each facility: (1) When regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks. This requirement was not met based on statements that found residents were left unattended by facility staff. This posed an immediate risk to residents.the state’s words, verbatim · CDSS document, Aug 8, 2025

Plan of correction: Licensee will submit a plan for normal and emergency fill in staff to the department by the POC date of 8/9/25. An office meeting may also be scheduled. Civil penalties applied

Type of visit: Case Management - Health Checks

During the case management visit conducted on June 4, 2025, LPA Todd Tryon, Licensing Program Manager, Troy Ordonez met with Elizabeth Weeks. During the visit, it was determined that the facility failed to correct the following deficiencies 87411(g) Personnel Requirements- based on interviews and the facility staff roster that showed only the administrator has criminal record clearance. Two of the three do not have clearance and the third is not associated. 87411(a) Personnel Requirements-General, Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. Based on interviews where caregiver stated she had no training prior to working, 87466-Observation of the resident-based on interviews, the doctor was not notified of the fall, 87405 (a) Administrator - Qualifications and Duties- based on interviews and observations, there is no qualified administrator or designated substitute. 87411(c) Personnel Requirements-All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training. Based on interviews where caregiver stated she had no training prior to working. 87465(h) (5) Incidental Medical and Dental Care-based on observation, LPA observed medication set up for a week in a medication box labeled Monday through Friday. 87412 (f) Personnel Records-based on interviews where no one knew where the records are being kept. 87411(c) (1) Personnel Requirements-based on interviews staff admitted they didn't have first aid by the due date of June 3, 2025. As a result, civil penalties were assessed in accordance with Title 22, California Code of Regulations. During today’s visit, civil penalties were assessed. The staff on site was able to write a plan of correction for each of the citations, and the citations that were issued were corrected on the spot today. In respect to the air conditioning system that was found to be non-functional, the facility is required to conduct daily temperature checks. The facility must submit daily temperature readings from various resident rooms and common areas to LPA Todd Tryon via email at john.tryon@dss.ca.gov . Submissions must begin on June 5,2025 and continue daily until written confirmation is received from the Department that the requirement has ended. The facility must conduct daily temperature checks in all resident rooms and common areas. The facility has stated that repairs to the air conditioning system will occur on 6/4/2025. The facility proof of repairs to the air conditioning system to LPA Todd Tryon. During the visit, citation was issued issued for a broken window on the front door. Deficiencies will be cited, and a Plan of Correction will be due within 24 hours. This will result in a Type A citation due to the immediate potential risk to resident health and safety. The home will continue to do daily room temperature checks in resident rooms and common area; and send in temperature readings to LPA daily. Readings will be submitted to LPA by 7:00 p.m. each day. If reading is not submitted by 7:00 p.m. each day, During visit the LPAs noted cameras in common areas of the facility. This is just a reminder that audio recording is not allowed in the care facility. Also, no cameras are allowed at all in the bedrooms. Proof of clearance for Plans of Correction given; deficiency cited today as per Title 22; resources provided to staff; Appeal Rights provided, exit interview conducted. The Department will continue to make unannounced Health and Safety visits until corrections are made and air conditioner is functioning properly.the state’s words, verbatim · CDSS document, Jun 4, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Jun 5, 2025

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This regulatoni is not met as evicenced by: Through observation LPA's noted that the window in the front door of the house is broken, and there is loose glass with sharp edges hanging from the window, posing a potential health and safety risk.the state’s words, verbatim · CDSS document, Jun 4, 2025

Plan of correction: Staff member indicated that the broken glass will be removed from the door, and a temporary cover/patch will be placed in the place of the window until the home is able to replace the window, Temporary fix to be completed by 6/5/2025. Staff to submit a photo of patch by 6/5/2025; and a plan for permanent replacement of the window.

Type of visit: Case Management - Health Checks

On 6/3/2025 LPA Tryon arrived at the facility unannounced to do a health and wellness/safety check of residents. LPA met with staff Elizabeth Weeks. It was reported that on 5/30/2025 the temperature in the home was 95 degrees F., when the outside temperature was 105 degrees F. LPA Hiratsuka had visited the home on 6/2/2025 to open a complaint related to that issue. She found the inside temperature in the house to be 80 degrees F. It was also found that licensee is out of the country; and staff at the facility did not have criminal record clearance, file/documentation, and no training. Citations were issued on 6/2/2025. Upon arrival today, LPA found that the owner's husband had purchased a portable air conditioner and placed it in the living room, with a tube out the front window. The house temperature inside felt reasonably comfortable. LPA checked with residents who stated they are doing well. The thermostat in the hallway read 77 degrees F. Resident rooms were checked and were at about 78 degrees F. LPA's small thermometer read approximately 78 degrees at the dining room table. LPA found that the resident room off the kitchen is set up like an apartment with its own bathroom, kitchen, etc. The unit actually has a small air conditioner built into the wall above the back door that leads outside. Resident said that the AC in her room works. She did not have it on when I visited, because she was comfortable without it at the moment. The temperature in the living room had leveled out, and resident actually asked staff to turn the AC up (warmer) as it felt too cool for her. LPA also discussed putting "hydration stations" in the house for residents to get water. LPA spoke by phone with licensee Paunitta Gray. LPA explained that the temperature in the house seems okay today with the portable AC in place. We also discussed the need to have all staff fingerprinted immediately; and that a civil penalty will run until cleared. LPA checked bedrooms and they were comfortable, with temperature readings of 77 to 78 degrees F. No deficiencies issued at this visit. Exit interview conducted with Lawrance Gray..the state’s words, verbatim · CDSS document, Jun 3, 2025

Allegation investigated: Facility too hot for residents

Licensing Program Analyst Kerry Hiratsuka conducted the investigation into the allegation above. On May 30, 2025, the Department was notified that on May 30, 2025, the facility’s air conditioning was non-functional during extreme temperatures—105°F outside and 95°F inside—placing residents at immediate risk. On June 2, 2025, the Department made an unannounced health and safety visit to the facility, the department has concluded the facility’s air conditioner is not working properly. During phone interview with a staff member, the staff member claimed the air conditioner was “working,” it was not blowing cool air. An AC repair appointment was reportedly scheduled, but no evidence of repair was available. LPA confirmed the facility interior was 80°F, with a forecasted outdoor high of 86°F for Auburn, CA. The prior reported indoor temperature was 95°F. Thermometer is reading 80 degrees. Substantiated Based on the information gathered through interviews, LPA was able to determine that the allegation is substantiated. Therefore, the Department finds the allegation to be Substantiated. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Please see 9099-D for the deficiency citedthe state’s words, verbatim · CDSS document, Jun 2, 2025 · control 59-AS-20250602105134

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(b) · Plan of correction due date: Jun 3, 2025

Maintenance and Operation. A comfortable temperature for residents shall be maintained at all times. This requirement was not met as evidence based on interviews. The husband of the administrator stated the air conditioner only blew hot air, the caregiver stated she doesn't know how to turn on the air condtioner, and residents and a witness who stated it was very hot, which poses an immedaite health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Jun 2, 2025

Plan of correction: By 06/03/2015, the licensee shall come up with a plan of correction to ensure the facility is maintained at a temperature that is comfortable for residents and to ensure alls staff know how to use the temperature controls.

Type of visit: Case Management - Deficiencies

On June 2, 2025, during the course of investigation, the department has observed multiple serious concerns about staffing, supervision, resident care, and overall facility operation during the licensee’s absence from the country. The department discovered one staff member was present and providing care, LPA spoke to a staff member on the phone, and was informed there is a third caregiver that was scheduled to show up later this afternoon. LPA observed two of the three do not have criminal record clearance. One does have criminal record clearance but is not associated to the facility. No personnel files were available for either but when a staff member arrived he showed LPA one record that is not for this facility. LPA observed the staff on duty during this visit doesn’t appear to have any training. Caregiver just admitted she has not had any training to take care of the residents. LPA couldn’t obtain access to the staff files to confirm if they staff have had any training because the administrator is not available. Resident had a fall on June 1, 2025, and facility staff didn’t seek medical attention despite the resident requesting to go. LPA observed medications are prepared seven days in advance and Title 22 regulations require medications to stay in their original container. One caregiver's first aid and CPR are expired and one does not have any. Based on deficiencies during 10/02/2024 annual visit and complaint visit on 10/24/2024 and case management visit conducted on 10/24/2024, it shows that there is no qualified administrator operating the facility. Deficiencies cited on the LIC 809-D, per Title 22 Regulations. Exit interview conducted. A copy of the report has been issued. Failure to correct the deficiencies may result in Civil penalties being assessed. $1000.00 IMMEDIATE CIVIL PENALTIES ISSUED due to three staff members working with no criminal record clearance. Appeal Rights provided.the state’s words, verbatim · CDSS document, Jun 2, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(g) · Plan of correction due date: Jun 3, 2025

Personnel Requirements – General. Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (1) Obtain a California clearance or a criminal record exemption as required by law or Department regulations This requirement was not met as evidence based on interviews and the facility staff roster that showed only the administrator has criminal record clearance, Two of the three do not have clearance and the third is not associated. which poses an immedaite health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Jun 2, 2025

Plan of correction: By 06/03/2025, Licensee shall ensure all staff who work at this facility has criminal record clearance and associated prior to working at the facility. Licensee shall submit a written statement stating how they shall ensure the staff all have criminal record clearance and association prior to working. Immediate civil penalties of $100.00 assessed.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87411(a) · Plan of correction due date: Jun 3, 2025

Personnel Requirements – General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs… This requirement was not met as evidence based on interviews where caregiver stated she had no training prior to working, which poses an immedaite health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Jun 2, 2025

Plan of correction: By 06/03/2025, Licensee shall submit a written plan of correction how they shall ensure all staff have the required training per Title 22 Regulations both prior to working by themselves and after.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(c) · Plan of correction due date: Jun 3, 2025

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 This requirement was not met as evidence based on interviews where caregiver stated she had no training prior to working, which poses an immedaite health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Jun 2, 2025

Plan of correction: By 06/03/2025, Licensee shall submit a written plan of correction how they shall ensure all staff have the required training per Title 22 Regulations both prior to working by themselves and after.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(h)(5) · Plan of correction due date: Jun 3, 2025

Incidental Medical and Dental Care The following requirements shall apply to medications which are centrally stored: Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement was not met as evidence based on observation, LPA observed medication set up for a week in a medication box labeled Monday through Friday, which poses an immediate health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Jun 2, 2025

Plan of correction: By 06/03/2025, Licensee shall come up with a written plan of correction on how they shall ensure all medication stays in their original container until being distributed.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87412(f) · Plan of correction due date: Jun 3, 2025

Personnel Records All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. This requirement was not met as evidence based on interviews where no one knew where the records are being kept, which poses an immediate health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Jun 2, 2025

Plan of correction: By 06/03/2025, Licensee shall submit a written plan of correction how they shall ensure staff records are available to the licensing agency upon request.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87411(c)(1) · Plan of correction due date: Jun 3, 2025

Personnel Requirements – General. (c) 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. Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement was not met as evidence based on interviews staff admitted they didn't have first aid, which poses an immediate health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Jun 2, 2025

Plan of correction: By 06/03/2025, Licensee shall ensure all staff have first aid training prior to working.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Jun 3, 2025

Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes ...and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as... are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not met as evidence based on interviews, the doctor was not notified of the fall, which poses an immediate health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Jun 2, 2025

Plan of correction: By 06/03/2025, Licensee shall submit a written plan of correction on how they shall ensure reporting requirements are followed.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87405(a) · Plan of correction due date: Jun 3, 2025

Administrator - Qualifications and Duties. All facilities shall have a qualified and currently certified administrator. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. This requirement was not met as evidence based on interviews and observations, there is no qualified administrator or designated substitute which poses an immediate health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Jun 2, 2025

Plan of correction: By 06/03/2023, Licensee shall ensure there are at minimum a qualified substitute when the administrator is not present in the facility. The licensee shall submit a written plan of correction.

Type of visit: Prelicensing

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.the state’s words, verbatim · CDSS document, Feb 5, 2025

Type of visit: Office

COMP II by CAB successfully completed Facility Type: RCFE Application Type: CHOW Capacity: 6 Census (if any clients in care): 2 Method: Telephone call with CAB COMP II Participants: Paunitta Gray, Administrator/Owner; Shannon Betker, analyst. Applicant/administrator participated in COMP II at CAB via telephone call with analyst at CAB. Identification of the applicant and administrator was verified by confirming driver’s license number. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant and administrator were advised to email/fax signed LIC 809 with copy of photo ID to CAB. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Jan 30, 2025