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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317002736
Report Date: 09/19/2024
Date Signed: 09/19/2024 11:47:34 AM

Document Has Been Signed on 09/19/2024 11:47 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'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:
09/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Gary JohnsonTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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On 9/19/2024 Licensing Program Analyst Todd Tryon arrived at the facility to conduct a Required-1 Year inspection. LPA met with Gary Johnson.

LPA toured the facility with staff to ensure the health and safety of residents in care. Areas toured include but are not limited to four (3) resident rooms, common areas, three (3) bathrooms, kitchen, storage areas and back yard. In the areas toured no immediate health, safety, violations were observed. 3 Staff and 2 resident files were reviewed. Medications were also viewed.



Common area was clean and in good repair. New furniture has been obtained for the common areas downstairs. All bedrooms had required furniture, bedding, and lighting. Bathrooms were clean and in good repair. Kitchen was clean and in good repair. Cooking/dining equipment and utensils were present. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food. Medication is locked in a locked closet.

First aid kit present and stocked. Fire extinguisher fully charged. Smoke detectors are all operational. Carbon monoxide detector installed. All employees requiring background checks are cleared. All required postings are displayed within facility.

No pools/bodies of water are on premises. No firearms are on premises. Disaster drills are conducted monthly.

The facility is in general compliance. No deficiencies are being cited as a result of today’s inspection.



Exit interview conducted and copy of report was provided.

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2024
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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