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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317005123
Report Date: 07/22/2026
Date Signed: 07/22/2026 02:32:41 PM

Document Has Been Signed on 07/22/2026 02:32 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
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME:PAULETTE, PHOEBE & HOWARD'S FAMILY HOMEFACILITY NUMBER:
317005123
ADMINISTRATOR/
DIRECTOR:		HUNTSBERRY, HOWARDFACILITY TYPE:
735
ADDRESS:1899 DELOUCH DRTELEPHONE:
(916) 409-9391
CITY:LINCOLNSTATE: CAZIP CODE:
95648
CAPACITY: 4CENSUS: 3DATE:
07/22/2026
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:HOWARD HUNTSBERRY, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived on 7/22/26 to conduct a follow-up visit after receiving two Facility Action Reports (dated 7/1/26 and 7/6/2026) from ALTA Regional Center. LPA Mirlohi met with Administrator Howard and explained the purpose of the visit.

LPA and Howard discussed the Facility Action Report (FAR) dated 7/1/2026 regarding staffing schedules based on the Regional Center guidelines and required staffing ratio. LPA requesting staffing schedules from April to Current.

Based on the Facility Action Report (FAR) dated 7/6/26 there were several deficiencies observed. There were missing required documents from staff and resident files. S1’s facility file did not have a health screening with TB clearance. Additionally, R1’s file did not contain a signed copy of the Personal Rights LIC613.

There were several discrepancies observed regarding medication management and documentation. R2’s Centrally Stored Medication Destruction Record did not contain symptoms for reason of use for 5 medications. R1 was also prescribed Acetaminophen 500 mg for 15 days in March 2026. The medication is still on hand at the facility. Additionally, R1’s varenicline medication order states 1 tab after meals while it is being administered 1x daily at 8am.

Deficiencies cited on 809-D. Exit interview conducted. A copy of this report and appeal rights were provided.

Troy Ordonez
Bethany Mirlohi
DATE: 07/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 07/22/2026 02:32 PM - It Cannot Be Edited


Created By: Bethany Mirlohi On 07/22/2026 at 01:40 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: PAULETTE, PHOEBE & HOWARD'S FAMILY HOME
FACILITY NUMBER: 317005123

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/23/2026
Section Cited
CCR
80075(b)

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80075 Health Related Services 80075(b)
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.
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Administrator will schedule medication training for all staff within 24 hours. Training to be completed by 8/4/26. Training to cover medication administration, documentation, and MAR accuracy. Facility to provide LPA with staff sign-in sheets and training materials.
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This requirement was not met as evidenced by R1 being prescribed Acetaminophen 500 mg beginning 3/26 for 15 days and the medication is still on hand. This poses a direct threat to the health and safety of clients in care.
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Type B
08/04/2026
Section Cited
CCR80065(g)(1)(g)

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80065 Personnel Requirements 80065(g)(1)(g) All personnel . . shall be in good health, and shall be physically, mentally, and occupationally capable of performing assigned tasks. . . (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis,
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Facility to provide completed physical and TB results for S1 to LPA.
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This requirement was not met as evidenced by S1 not having a physical and TB results in their personnel file. This poses an indirect 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.
Troy Ordonez
NAME OF LICENSING PROGRAM MANAGER:
Bethany Mirlohi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/22/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/22/2026 02:32 PM - It Cannot Be Edited


Created By: Bethany Mirlohi On 07/22/2026 at 01:49 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: PAULETTE, PHOEBE & HOWARD'S FAMILY HOME
FACILITY NUMBER: 317005123

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/04/2026
Section Cited
CCR
80072(d)

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80072 Personal Rights.
(d) At admission, a client and the client's authorized representative shall be personally advised of and given a list of the rights specified in Sections 80072(a)(1) through (10) and in the applicable Personal Rights sections of chapters 2 through 7.
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Facility to provide signed personal rights LIC613 to LPA
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This requirement was not met as evidenced by R1’s facility file not containing signed LIC613. This poses an indirect threat to the health and safety of clients in care.
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Type B
08/04/2026
Section Cited
CCR80075(b)(6)(D)(1)

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80075 Health Related Services 80075(b)(6)(D)(1)
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (6)(D) For every prescription and nonprescription PRN medication for which the licensee provides assistance . . . Both the physician's order and the label shall contain at least all of the following information.(1)The specific symptoms which indicate the need for the use of the medication.
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Administrator to review current centrally stored medication and destruction records for all residents, revise with all required information, and send completed forms to LPA for all current clients.
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This requirement was not met as evidenced by R2’s CSMDR missing required information. This poses an indirect 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.
Troy Ordonez
NAME OF LICENSING PROGRAM MANAGER:
Bethany Mirlohi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/22/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2026


LIC809 (FAS) - (06/04)
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