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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317005123
Report Date: 11/22/2021
Date Signed: 11/22/2021 01:41:36 PM

Document Has Been Signed on 11/22/2021 01:41 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
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: 2DATE:
11/22/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Yurell HuntsberryTIME COMPLETED:
02:00 PM
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LPA Lusby arrived on Monday November 22, 2021 to further gather additional information regarding an incident that occurred on November 17, 2021. Prior to the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask. LPA was screened by staff prior to entry.

LPA interviewed Administrator Howard Huntsberry over the phone. Administrator agreed to email LPA a copy of the staffing schedule pertaining to R1. LPA obtained copies of R1's client chart documents. LPA interviewed staff regarding R1. LPA toured client's room at the facility.

Exit interview conducted. A copy of this report was left at the facility.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Melissa Lusby
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2021
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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