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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317002736
Report Date: 11/06/2024
Date Signed: 11/06/2024 11:07:42 AM

Document Has Been Signed on 11/06/2024 11:07 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:
11/06/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Joey FredericksTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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On 11-6-2024 LPA Tryon visited the facility to amend a 9099 report dated 9/13/2024. On that date LPA had visited the facility to complete complaint #59-AS-20240626120926 While at the visit, LPA somehow inadvertently checked the 9099 finding for Unsubstantiated as Confidential, when it should have been Public. This visit is to correct that error.
LPA met with staff Joey Fredericks and completed the amended document on 11/6/2024 and obtained staff signature.

Exit interview conducted
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE: DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2024
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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