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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317002366
Report Date: 01/08/2025
Date Signed: 01/09/2025 10:03:22 AM

Document Has Been Signed on 01/09/2025 10:03 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/
DIRECTOR:		HOWARD HUNTSBERRYFACILITY TYPE:
735
ADDRESS:217 POET SMITH DRIVETELEPHONE:
(530) 537-2735
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY: 6CENSUS: 6DATE:
01/08/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Steven MackieTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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On 1/8/2025 LPA Tryon visited the facility to do an annual visit and inspection. LPA met with staff Steven Mackie.
LPA toured the house including common areas, kitchen, bedrooms, bathrooms, office area, yard.
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.

LPA reviewed 2 resident files..

LPA was also following up on issues that were cited by Alta California Regional Center at their Title 17 Visit on 12/4/2024.

At this time, LPA ran out of time to complete the visit due to looking into multiple issues related to the Title 17 review. LPA will need to complete the annual and Title 17 follow up at a later date.

Exit interview conducted.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE: DATE: 01/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/08/2025
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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