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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 317005123
Report Date: 12/29/2021
Date Signed: 12/29/2021 03:56:14 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/20/2021 and conducted by Evaluator Jacob Williams
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20211220153804
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:
12/29/2021
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Yurell Hunstberry, caregiver/Licensee's sonTIME COMPLETED:
04:10 PM
ALLEGATION(S):
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Uncleared adult working in facility
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Williams arrived unanounced and met with Yurell Huntsberry, caregiver, and spoke with Howard Huntsberry via phone in order to meet the 10-day requirement for the above allegation. Prior to initiating this 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 applied hand sanitizer before entering and wore surgical mask.

LPA investigated allegation, “Uncleared adult working in facility”. LPA spoke with staff and viewed weekly staff schedules for month of November to determine S1 had been working at facility. LPA then spoke with Care Provider Management Bureau and reviewed Guardian for S1's "determination status" which reads "In Process". The individual was never cleared to work or be inside the facility. The Due to the information gathered, this allegation is found to be substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. A civil penalty in the amount of $500 is being assessed. Exit interview conducted and appeal rights given.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Jacob WilliamsTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 25-AS-20211220153804
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
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 HOME
FACILITY NUMBER: 317005123
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/30/2021
Section Cited
CCR
87355(e)(1)
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87355 Criminial Record Clearance. (e)All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department
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The licensee will ensure that no individual without clearance or exemption is employed or present in the facility.
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Through interview with staff and reviewing prior weekly staff schedules, it was learned that staff S1 had been working at the facility as a 1-on-1. The licensee did not ensure that S1 had a criminal record clearance before working.
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LPA has reviewed the current staff schedule and has confirmed that S1 is no longer scheduled to work at the facility.
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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.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Jacob WilliamsTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2021
LIC9099 (FAS) - (06/04)
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