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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 317002366
Report Date: 06/29/2023
Date Signed: 06/29/2023 02:54:22 PM

Unsubstantiated


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
05/24/2023 and conducted by Evaluator Todd Tryon
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20230524140901
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:
06/29/2023
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:TIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff physically abused resident.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On June 29, 2023 LPA Tryon visited the facility to finish the complaint. LPA met with staff Steven Mackie.
LPA has reviewed information and I have spoken with the resident involved in the incident.
During my last visit on 5/26/2023, LPA met with resident, who completely recanted his story and allegations. He stated that the whole incident was caused by him, and staff in no way physically abusive. Staff was simply reacting to the behavior and attempted to de-escalate the situation and protect the residents. At this time it is not possible to say that everything went in the best way possible, but it appears that staff attempted to act appropriately in the situation; and resident claimed responsibility for the situation.

Allegation is Unsubstantiated. A finding of unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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