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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317005123
Report Date: 04/10/2023
Date Signed: 04/10/2023 11:54:32 AM

Document Has Been Signed on 04/10/2023 11:54 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
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:
04/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Yurell HuntsberryTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Melissa Parks arrived on Monday April 10, 2023 to conduct the annual inspection. LPA wore a surgical mask during todays visit.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA Parks reviewed client (4) and staff (4) files. All resident files contained the required paperwork. All staff files contained the required paperwork and training.

LPA Parks and Administrator Howard toured the facility together to ensure the health and safety of clients in care. The areas toured included bedrooms, kitchen, bathrooms, laundry room and garage. In the areas toured, there were no health or safety violations observed.

No deficiencies cited. Exit interview conducted. A copy of this report was emailed to the Administrator.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Melissa Parks
LICENSING EVALUATOR SIGNATURE: DATE: 03/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2023
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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