317005123-12-29-2021-25-AS-KHOS-CAEHP2-20220106052138

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 HOME		FACILITY NUMBER:	317005123
ADMINISTRATOR:	HUNTSBERRY, HOWARD		FACILITY TYPE:	735
ADDRESS:	1899 DELOUCH		TELEPHONE:	(916) 409-9391
CITY:	LINCOLN	STATE: CA	ZIP CODE:	95648
CAPACITY:	4	CENSUS: 2	DATE:	12/29/2021
		UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Yurell Hunstberry, caregiver/Licensee's son		TIME 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 Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Jacob Williams	TELEPHONE: (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)

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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)	1 2 3 4 5 6 7	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	1 2 3 4 5 6 7	The licensee will ensure that no individual without clearance or exemption is employed or present in the facility.
	8 9 10 11 12 13 14	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.	8 9 10 11 12 13 14	LPA has reviewed the current staff schedule and has confirmed that S1 is no longer scheduled to work at the facility.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Jacob Williams	TELEPHONE: (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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