<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317002366
Report Date: 07/19/2023
Date Signed: 07/20/2023 09:51:38 AM

Document Has Been Signed on 07/20/2023 09:51 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
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:
07/19/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Brandon MackieTIME COMPLETED:
04:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 7/19/2023 LPA visited the home to conduct a brief Case Management visit related to two incidents in the past week. Incidents involved a resident becoming upset at another resident and leading to police involvement. Incident reports were filed by the administrator, and subsequently an eviction notice. LPA was checking in with staff to find out the status of the situation, and to discuss what is needed for an eviction notice.

The resident is currently out of the facility and it is not clear if he will be released or what will come next at this point.

Facility plans to amend eviction notices and re-submit.

Exit interview conducted.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE: DATE: 07/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1