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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317002736
Report Date: 10/26/2022
Date Signed: 10/26/2022 03:49:43 PM

Document Has Been Signed on 10/26/2022 03:49 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
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:PAULETTE'S FAMILY HOMEFACILITY NUMBER:
317002736
ADMINISTRATOR:MACKIE, PAULETTEFACILITY TYPE:
735
ADDRESS:505 COORS LNTELEPHONE:
(530) 878-6752
CITY:AUBURNSTATE: CAZIP CODE:
95602
CAPACITY: 6CENSUS: 6DATE:
10/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Joey FrederickTIME COMPLETED:
04:00 PM
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On 10/26/2022 LPA Tryon visited the facility to do an annual visit. LPA met with staff Joey Frederick.
LPA toured the facility including common areas, kitchen, living and TV rooms, dining room, food storage, bedrooms, bathrooms, decks.
Smoke detectors installed. The facility has adequate food supplies, cleaners, plenty of PPE supplies etc.
House appears clean and adequately furnished.

LPA reviewed the Infection Control Section of the CARES Tool.

At this time, the facility appears to be in substantial compliance with regulations.

Exit interview conducted.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE: DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/26/2022
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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