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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 317005123
Report Date: 06/25/2024
Date Signed: 06/25/2024 03:14:35 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/13/2024 and conducted by Evaluator Melissa Parks
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20240513122017
FACILITY NAME:PAULETTE, PHOEBE & HOWARD'S FAMILY HOMEFACILITY NUMBER:
317005123
ADMINISTRATOR:HUNTSBERRY, HOWARDFACILITY TYPE:
735
ADDRESS:1899 DELOUCHTELEPHONE:
(916) 409-9391
CITY:LINCOLNSTATE: CAZIP CODE:
95648
CAPACITY:4CENSUS: 4DATE:
06/25/2024
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Howard HuntsberryTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Insufficient staff.
Staff live on the premises.
Facility is not reporting incidents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Melissa Parks arrived unannounced on Tuesday June 25, 2024, to complete and deliver findings to a complaint received on 5/13/2024. LPA met with Administrator Howard and explained the purpose of the visit. This was a joint visit with ALTA Service Coordinator Jona Diamond.

Throughout the course of the investigation, LPA interviewed the Administrator and staff. LPA reviewed staffing schedules and compared it with required hours required by ALTA. LPA reviewed R1-R4’s file at the facility including physicians report, MARs, medication lists, IPPs, and incident reports. The result of the investigation is as follows:

Allegation: Staff live on the premises.
LPA reviewed the fire clearance for the facility which was established in 2013. The fire clearance shows approval for 4 ambulatory clients. The facility sketch which was provided to the fire Department and the Department was not approved for/does not indicate a room for live-in staff. Therefore, this facility is
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Melissa Parks
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
Control Number 59-AS-20240513122017
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: PAULETTE, PHOEBE & HOWARD'S FAMILY HOME
FACILITY NUMBER: 317005123
VISIT DATE: 06/25/2024
NARRATIVE
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operating outside of their fire clearance. Since the fire clearance, there has been a small room/office that was built out of the garage and is now being used as staff living quarters.

Allegation: Insufficient staff.
LPA reviewed the facility’s staffing schedules from December 2023 to present. Based on the staffing schedule and staff interviews, LPA has determined that this facility has insufficient staffing. This is a level 4-I home which is required to have awake overnight staff. There is only one staff during the overnight shift who goes to sleep after the clients have all ‘settled down for the night’. This facility is required to provide 144 awake staffing hours per week. Therefore, this facility is operating with insufficient staff and is not staffing according to their agreement with ALTA Regional Center.


Allegation: Facility is not reporting incidents
LPA reviewed an incident report submitted to ALTA Regional Center regarding R4’s behavior on 3/8/2024. R4 told staff that he could not sleep. Staff provided R4 with a PRN sleep aid medication. R4 later became aggressive and became combative with staff. This incident was not reported to the Department. LPA only became aware of the incident while reviewing R4’s file. Therefore, LPA has determined that the Facility is not following reporting requirements.

Deficiency cited on 9099-D. Appeal rights were printed and given.

Exit interview conducted. A copy of this report was left at the facility.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Melissa Parks
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 59-AS-20240513122017
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: PAULETTE, PHOEBE & HOWARD'S FAMILY HOME
FACILITY NUMBER: 317005123
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/26/2024
Section Cited
CCR
85065.5(b)
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85065 Personnel Requirements
(b) The licensee shall employ staff as necessary to ensure provision of care and supervision to meet client needs. This requirement was not met as evidenced by
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Administrator agrees to submit a plan to LPA which details hiring staff in order become complaint with 144 weekly hours and awake overnight staff.
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the facility not providing awake overnight staff as part of their staffing requirements through ALTA Regional Center. This is a direct threat to the health and safety of clients in care.
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Type A
06/26/2024
Section Cited
CCR
80020(a)
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Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshall. This requirement was not met as evidenced by the facility
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Administrator agrees to submit an updated facility sketch which shows the staff room. LPA will then work with the local Fire Department to schedule a facility visit for approval/denial.
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utilizing a bedroom/office for staff which was not approved by the Fire Department. This is a direct threat to the health and safety of clients in care.
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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.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Melissa Parks
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/13/2024 and conducted by Evaluator Melissa Parks
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20240513122017

FACILITY NAME:PAULETTE, PHOEBE & HOWARD'S FAMILY HOMEFACILITY NUMBER:
317005123
ADMINISTRATOR:HUNTSBERRY, HOWARDFACILITY TYPE:
735
ADDRESS:1899 DELOUCHTELEPHONE:
(916) 409-9391
CITY:LINCOLNSTATE: CAZIP CODE:
95648
CAPACITY:4CENSUS: 4DATE:
06/25/2024
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Howard HuntsberryTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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2
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9
Medication management.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Melissa Parks arrived unannounced on Tuesday June 25, 2024, to complete and deliver findings to a complaint received on 5/13/2024. LPA met with Administrator Howard and explained the purpose of the visit. This was a joint visit with ALTA Service Coordinator Jona Diamond.

Throughout the course of the investigation, LPA interviewed the Administrator and staff. LPA reviewed staffing schedules and compared it with required hours required by ALTA. LPA reviewed R1-R4’s file at the facility including physicians report, MARs, medication lists, IPPs, and incident reports. The result of the investigation is as follows:

Allegation: Medication management.
LPA reviewed medication lists for all clients. LPA determined that all current prescribed medications are on R1-R4’s MARs. Additionally, LPA reviewed residents MARs and did not see any medications which
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Melissa Parks
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 59-AS-20240513122017
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: PAULETTE, PHOEBE & HOWARD'S FAMILY HOME
FACILITY NUMBER: 317005123
VISIT DATE: 06/25/2024
NARRATIVE
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were not given. Therefore, LPA could not determine if medications were not being given according to physicians orders.

Based on information obtained during the investigation, LPA finds the allegation to be UNSUBSTANTIATED- a finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred.

Exit interview. A copy of this report was emailed to the Administrator.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Melissa Parks
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 59-AS-20240513122017
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: PAULETTE, PHOEBE & HOWARD'S FAMILY HOME
FACILITY NUMBER: 317005123
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/10/2024
Section Cited
CCR
80061(a)(b)(E)
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(a) Each licensee or applicant shall furnish to the licensing agency reports ..
(b) Upon the occurrence, during the operation of the facility . . .
(E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client.
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Administrator agrees to submit a statement of understanding regarding reporting requirements.
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This requirement was not met as evidenced by incident reports from March which were sent to ALTA but not CCL. This is a possible threat to the health and safety of clients in care.
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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.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Melissa Parks
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 7