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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 317005123
Report Date: 02/26/2021
Date Signed: 02/26/2021 12:14:40 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/15/2020 and conducted by Evaluator Melissa Lusby
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20201215143512
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: 3DATE:
02/26/2021
UNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Howard HuntsberryTIME COMPLETED:
12:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident is not treated with respect
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Melissa Lusby contacted the facility via telephone to conclude a complaint investigation on 1/28/2021 due to COVID-19 and pre-cautionary measures. LPA identified herself and discussed the purpose of the call and the elements of the complaint with Howard Huntsberry. LPA Lusby interviewed Licensee/Administrator Howard Huntsberry, Staff (s1), and clients who live a the facility. Additionally, LPA Lusby reviewed C1's current IPP and care plan. Based on information obtained, LPA finds the above 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 the evidence to prove that the alleged violation occurred. There are no deficiencies being cited per Title 22 Regulations, Division 6, Chapter 8. Exit interview conducted. Appeal rights were printed and given to Administrator. A copy of this report was emailed to the Administrator to review, sign and send back.
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Melissa LusbyTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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