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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002607
Report Date: 03/21/2023
Date Signed: 03/21/2023 03:54:49 PM

Document Has Been Signed on 03/21/2023 03:54 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME:COLLYER HOMEFACILITY NUMBER:
455002607
ADMINISTRATOR:VICTORINE, CHAYLENEFACILITY TYPE:
735
ADDRESS:699 COLLYER DRTELEPHONE:
(530) 244-7513
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY: 4CENSUS: 4DATE:
03/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Chaylene VictorineTIME COMPLETED:
04:05 PM
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LPA Hiratsuka conducted this unannounced annual visit. LPA wore a surgical mask and observed all staff wearing masks. Administrator Chaylene Victorine, arrived and completed the visit. LPA toured with Caregiver Wendel Johnston.

This facility has four private resident rooms, one full private bathroom, and one full common bathroom. There is a laundry room that leads to the garage. The facility has an ample supply of perishable and nonperishable food.

Several topics were discussed.

No deficiencies cited.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2023
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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