317002736-11-6-2024-59-AS-KHOS-DAWM2J-20241111081336

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 317002736
Report Date: 09/13/2024
Date Signed: 11/06/2024 11:10:15 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/26/2024 and conducted by Evaluator Todd Tryon

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20240626120926

FACILITY NAME:	PAULETTE'S FAMILY HOME		FACILITY NUMBER:	317002736
ADMINISTRATOR:	MACKIE, PAULETTE		FACILITY TYPE:	735
ADDRESS:	505 COORS LN		TELEPHONE:	(530) 878-6752
CITY:	AUBURN	STATE: CA	ZIP CODE:	95602
CAPACITY:	6	CENSUS: 6	DATE:	09/13/2024
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Steven Mackie, Staff		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Facility is not reporting incidents

INVESTIGATION FINDINGS:

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Regarding the allegation that the facility is not reporting incidents, LPA spoke with staff, and is not able to ascertain whether there may or may not have been times that incidents were not reported in the past. The facility has reported some incidents when they occurred. At this time, LPA finds the allegation to be unsubstantiated.

A finding that an allegation is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove the the alleged violation occurred.

No deficiencies were cited at this visit.

Exit interview conducted; appeal rights provided.
This is an amended document

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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