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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317002366
Report Date: 12/11/2023
Date Signed: 12/11/2023 04:26:56 PM

Document Has Been Signed on 12/11/2023 04:26 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
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:
12/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Steven MackieTIME COMPLETED:
05:00 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 12/11/2023 LPA Tryon visited the facility to conduct an annual review. LPA met with Steven Mackie.
LPA toured the house including common areas, kitchen, bedrooms, bathrooms, office area.
The food supplies look adequate to meet the requirement of 2 days perishable and 7 days non-perishable. Refrigerator and freezer at appropriate temperatures.
The house was clean and functional. Bathrooms are clean and plumbing works.
Bedrooms have appropriate furniture.
Smoke detectors installed, as well as carbon monoxide detector. .

LPA reviewed the CARE Tool with staff.

At this time, the facility appears to be in substantial compliance with the regulations. No deficiencies were cited at this visit.

Exit interview conducted.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE: DATE: 12/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2023
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