<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002607
Report Date: 01/10/2024
Date Signed: 01/10/2024 02:07:30 PM

Document Has Been Signed on 01/10/2024 02:07 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:COLLYER HOMEFACILITY NUMBER:
455002607
ADMINISTRATOR:VICTORINE, CHAYLENEFACILITY TYPE:
735
ADDRESS:699 COLLYER DRTELEPHONE:
(530) 244-7513
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY: 4CENSUS: 4DATE:
01/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:21 PM
MET WITH:Administrator Chaylene Victorine TIME COMPLETED:
02:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 01/10/2024, Licensing Program Analyst (LPA) Jaynae Boyles, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA met with Facility Administrator, Cheylene Victorine and explained the purpose of the visit.

LPA Boyles and Administrator toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, four (4) resident bedrooms, garage, backyard, and common restrooms.

LPA observed the facility to be clean, in good repair and odor-free and each bathroom to have the necessary grab bars, paper towels, trash can with lids and 20-second hand-washing poster.

Facility has a 2-day perishable and a 7-day non-perishable amount of food. Hot water temperature was measured in three locations throughout the facility, which was 118 F. LPA observed one (1) fire extinguishers, six (6) fire detectors, and two (2) carbon monoxide detectors. LPA observed the first Aid Kit to be complete and ready for use.

In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA reviewed a total of four (4) residents' files and three (3) staff files.

Several topics were discussed.

No deficiencies are being cited as a result of today’s inspection.

Exit interview conducted and copy of report left at the facility.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Jaynae Boyles
LICENSING EVALUATOR SIGNATURE: DATE: 01/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/10/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1