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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317005123
Report Date: 09/04/2024
Date Signed: 09/04/2024 04:41:09 PM

Document Has Been Signed on 09/04/2024 04:41 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:PAULETTE, PHOEBE & HOWARD'S FAMILY HOMEFACILITY NUMBER:
317005123
ADMINISTRATOR/
DIRECTOR:		HUNTSBERRY, HOWARDFACILITY TYPE:
735
ADDRESS:1899 DELOUCH DRTELEPHONE:
(916) 409-9391
CITY:LINCOLNSTATE: CAZIP CODE:
95648
CAPACITY: 4CENSUS: 4DATE:
09/04/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:30 PM
MET WITH:Howard HuntsberryTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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An informal conference was conducted on Wednesday September 4, 2024, via Microsoft Teams. The purpose of this informal conference meeting is to discuss deficiencies discovered during a complaint investigation which began in May 2024. Present in the meeting is Licensing Program Manager (LPM) Maribeth Senty, Licensing Program Analyst (LPA) Melissa Parks, Jona Diamond, ALTA Regional Service Coordinator, BJ Thompson, ALTA Regional Client Services Manager, and Licensee Howard Huntsberry. The informal conference process was explained during this meeting.

The facility has been cited 3 times in the last year. The facility was cited under the following regulations: personnel requirements, fire clearance, and reporting requirements. The facility was cited for two Type A citations, and one Type B citations.

The licensee was told that this Informal conference is a part of the Administrative Action process and that further citations may result in an elevation to a formal non-compliance conference, which could lead to a referral to the Department's legal division for possible revocation of license.

Issues discussed during the meeting were:


· Staffing
· Awake, overnight staff
· Plan for nonpermitted staff office/room
· Facility vehicle
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Melissa Parks
LICENSING EVALUATOR SIGNATURE: DATE: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/04/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 317005123
VISIT DATE: 09/04/2024
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The facility has stated they will do the following to achieve continued and substantial compliance:
· Hire and onboard two additional staff by 10/4/2024
· Purchase and have a facility vehicle by 10/4/2024
· Work with the Lincoln Building Department in order to obtain permits for staff room. Staff room will not be used until it has been cleared by the Fire Inspector.

No deficiencies were cited during today’s meeting.

An exit interview was conducted. A copy of this report was provided.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Melissa Parks
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024
LIC809 (FAS) - (06/04)
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