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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317002366
Report Date: 09/03/2021
Date Signed: 09/03/2021 01:36:50 PM

Document Has Been Signed on 09/03/2021 01:36 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
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: 3DATE:
09/03/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Howard HuntsberryTIME COMPLETED:
01:00 PM
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LPA Tryon arrived at the facility at 11:00 a.m. on 9/3/21 to perform an annual visit using the Infection Control Domain. Prior to the visit, LPA had checked with the facility to ensure they do not have any COVID Positive Residents or staff. LPA did a self-screening by taking temperature and reviewing possible symptoms. LPA wore a surgical mask and used hand sanitizer. LPA met with Howard Huntsberry.
LPA toured the facility including common areas, kitchen, bedrooms, bathrooms, hallways, yard.

LPA reviewed the infection control domain with the Administrator. LPA requested a copy of most recent Administrator Certificate, copy of liability insurance, and current staff schedule.

The facility appears to be in substantial compliance at this time.

Exit interview conducted
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE: DATE: 09/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/03/2021
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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