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as prepared by Residential Care Services for the Locator website.

Residential Care ServicesInvestigation Summary Report

Provider/Facility: A LITTLE PIECE OF HEAVEN (687104) Intake ID(s): 3671660

License/Cert. #: AF524200Investigator: Singer, Jamie Region/Unit: RCS Region 2/Unit I Investigation

Date(s):10/28/201910/29/2019

through

Complainant Contact Date(s): 10/22/2019, 10/29/2019Allegations:#1. The adult family home (AFH) had not paid the annual licensing fee and was operating the AFH without a valid license.

Investigation Methods:Sample: Resident Observations: Adult Family Home

Environment, ResidentAppearance, Resident toStaff Interaction, Foodand Household Supplies

Interviews: Resident, EntityRepresentative.

Record Reviews: Resident Records, StaffRecords, DepartmentRecords

Allegation Summary:#1. Observation found the AFH provided care and services to five residents. The AFH was operating with all required utilities andsufficient staffing, food and supplies. The AFH failed to pay the annual licensing fee due 08/15/19 and was operating without avalid license.

Unalleged Violation(s): Yes No

Conclusion /Action:

Failed Provider Practice Identified /Citation(s) Written

Failed Provider Practice Not Identified /No Citation Written

See Statement of Deficiencies dated 10/29/19.

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This document was prepared by Residential Care Services for the Locator website.

This document w

as prepared by Residential Care Services for the Locator website.

This document w

as prepared by Residential Care Services for the Locator website.