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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317002366
Report Date: 01/26/2022
Date Signed: 01/27/2022 08:16:22 AM

Document Has Been Signed on 01/27/2022 08:16 AM - 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:
01/26/2022
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:David HarrisTIME COMPLETED:
04:00 PM
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LPA Tryon visited the facility to conduct an annual visit. Before visiting, LPA had done a COVID screening by taking my temperature and screening possible symptoms. LPA wore an N-95 face mask in the facility. LPA met with staff David Harris.

LPA used the Infection Control section of the annual tool LPA toured the facility including common areas, kitchen, rooms, bathrooms, yard, etc. Facility has an adequate food supply.

The facility appears to be in substantial compliance with the regulations.

Exit interview conducted.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE: DATE: 01/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2022
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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