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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317002736
Report Date: 06/10/2026
Date Signed: 06/10/2026 12:01:37 PM

Document Has Been Signed on 06/10/2026 12:01 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'S FAMILY HOMEFACILITY NUMBER:
317002736
ADMINISTRATOR/
DIRECTOR:		MACKIE, PAULETTEFACILITY TYPE:
735
ADDRESS:505 COORS LNTELEPHONE:
(530) 878-6752
CITY:AUBURNSTATE: CAZIP CODE:
95602
CAPACITY: 6CENSUS: 6DATE:
06/10/2026
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:40 AM
MET WITH:Staff Fredricks and Sophia Sontay TIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cassandra Mikkelson and Licensing Program Manager (LPM) Laura Munoz arrived to the facility today to follow up on an incident that occurred at the facility on 11/27/2025. LPM Munoz spoke with Administrator Gary Johnson via phone to inform of visit.

On 11/27/2025, S1 assaulted R1 resulting in resident sustaining closed fracture of left orbit and closed fracture of left condylar process of mandible. Interviews and records review indicated that S1 and R1 were watching a football game drinking alcohol. At some point during the game, S1 and R1 got into a verbal altercation. R1 pushed S1 at which time S1 hit R1 in the face causing significant injury. This incident was observed by other another staff member who separated S1 and R1. When the licensee was made aware of the altercation, S1’s employment at the facility was terminated. On 04/14/2026, the RO served the facility with an immediate exclusion notice for S1.

As a result of this visit, a deficiency was cited pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8. An immediate civil penalty in the amount of $500 was assessed per Health and Safety Code 1548 for a violation regarding personal rights. Deficiency is listed on 809-D page.

The licensee was informed during today’s visit that a civil penalty is under review and may be assessed at a future date according to Health and Safety Code §1569.49.



Exit interview was conducted with Administrator. A copy of this report and appeal rights were provided. Signatures on these forms acknowledges receipt of these documents.
NAME OF LICENSING PROGRAM MANAGER: Laura Munoz
NAME OF LICENSING PROGRAM ANALYST: Cassandra Mikkelson
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/10/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 06/10/2026 12:01 PM - It Cannot Be Edited


Created By: Cassandra Mikkelson On 06/10/2026 at 08:23 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: PAULETTE'S FAMILY HOME
FACILITY NUMBER: 317002736

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/10/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/11/2026
Section Cited
CCR
80072(a)(3)

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80072 (a)(3) Personal Rights
(a)... each client shall have personal rights which include, but are not limited to, the following: (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with the daily living functions(...)
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Licensee and Administrator will attend non-compliance conference (NCC) scheduled on June 30, 2026.
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This was not met by evidenced by:
S1 physically assaulted R1 on 11/27/2025 causing serious bodily harm.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Laura Munoz
NAME OF LICENSING PROGRAM MANAGER:
Cassandra Mikkelson
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2026


LIC809 (FAS) - (06/04)
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