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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 317002366
Report Date: 05/04/2023
Date Signed: 05/04/2023 12:29:20 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/02/2023 and conducted by Evaluator Todd Tryon
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20230502134759
FACILITY NAME:PAULETTE & MATTIE'S FAMILY HOMEFACILITY NUMBER:
317002366
ADMINISTRATOR:HOWARD HUNTSBERRYFACILITY TYPE:
735
ADDRESS:217 POET SMITH DRIVETELEPHONE:
(530) 885-4319
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY:6CENSUS: 6DATE:
05/04/2023
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Steven MackieTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Facility backyard fence is in disrepair.
INVESTIGATION FINDINGS:
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On 5/4/2023 LPA Tryon visited the facility to open the complaint. LPA met with staff Steven Mackie.
LPA viewed the back yard and fence there is a section of the fence that is about 30 feet long that is partially leaning and partially down on the ground. Mr. Mackie said that they have been speaking with the homeowners insurance company to attempt to obtain some funding for the repair, but they have not had any success to date.

This broken fence appears that it could pose a potential threat to residents, staff or neighbors. Allegation is SUBSTANTIATED.

The following deficiency is cited as per Title 22 Regulations. Exit interview conducted, appeal rights given.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023
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 2
Control Number 59-AS-20230502134759
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: PAULETTE & MATTIE'S FAMILY HOME
FACILITY NUMBER: 317002366
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/05/2023
Section Cited
CCR
80087(a)
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The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
This regulation is not met as evidenced by: LPA learned that the fence around the back yard of the faciity is partially on the ground and partially hanging down for about 30 ft.
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The facility is in the process of contacting homeowners insurance for repair. The facility will cooperate with neighbors to ensure that the fence gets repaired/rebuilt for the safety of all involved.
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This poses a potential risk to residents, staff and neighbors.
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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.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023
LIC9099 (FAS) - (06/04)
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