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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317005123
Report Date: 03/04/2024
Date Signed: 03/04/2024 03:03:08 PM

Document Has Been Signed on 03/04/2024 03:03 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
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:
03/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Yurell HuntsberryTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Melissa Parks arrived on Monday March 4, 2024 to conduct the unannounced annual inspection.

LPA met with staff Yurell and explained the purpose of the visit.

During today's visit, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed 4 client files and 2 staff files. All files contained the required paperwork.

LPA and Staff toured the facility together to ensure the health and safety of clients in care. Areas toured included bedrooms, bathrooms, laundry room, garage, kitchen, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. Facility is current on fire drills. First Aid kit was fully stocked. Chemicals were kept locked and inaccessible to clients.

No deficiencies cited. Exit interview conducted and copy of report left at the facility.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Melissa Parks
LICENSING EVALUATOR SIGNATURE: DATE: 03/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2024
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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