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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317002736
Report Date: 10/23/2024
Date Signed: 10/24/2024 10:31:18 AM

Document Has Been Signed on 10/24/2024 10:31 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: DATE:
10/23/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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On 10-23-2024 LPA Tryon visited the facility to amend a 9099 report dated 7/1/2024. On that date LPA had visited the facility to open a complaint. While at the visit, LPA somehow inadvertently checked the 9099 10-day visit report as Unsubstantiated in error. The outcome should have been marked as "Needs further investigation."
LPA met with staff Jordan Mackie and completed the amended document on 10/23/2024 and obtained staff signature.

Exit interview conducted.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE: DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/23/2024
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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