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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700646
Report Date: 01/11/2024
Date Signed: 01/11/2024 03:30:28 PM

Document Has Been Signed on 01/11/2024 03:30 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:CLAREMONT HOMEFACILITY NUMBER:
502700646
ADMINISTRATOR:HUDDLESTON, DOLORESFACILITY TYPE:
735
ADDRESS:3324 CLAREMONT AVENUETELEPHONE:
(530) 515-9078
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY: 4CENSUS: 4DATE:
01/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:House Manager Paul KoughnTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Jason Lund arrived at the facility unannounced to conduct an annual/required visit. LPA met with House Manager Paul Koughn. Staff called Administrator Dolores Huddleston who could not make the visit today, LPA explained the reason for the to all staff. Census: 4

LPA Lund & House Manager Paul Koughn and toured/inspected the facility is a single-story building with 4 resident bedrooms and 3 bathrooms. Facility has common areas, dining area, outdoor area, laundry room and kitchen. All bedrooms did have furnishings for all 4 residents. All bathrooms have a working toilet, and wash basin. 2 bathrooms have a shower. Adequate supply of 7-day non-perishable and 2- day perishables stored in the kitchen and pantry. Smoke alarms and 2 Carbon monoxide detectors were observed operational. Fire extinguishers were charged and mounted. Toxins were locked and stored in the laundry room. LPA Lund reviewed three staff and two client files.

An exit interview was conducted with House Manager Paul Koughn and Ms. Huddleston over the phone and a copy of this report was left.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/11/2024
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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