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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002607
Report Date: 03/13/2025
Date Signed: 03/13/2025 01:29:05 PM

Document Has Been Signed on 03/13/2025 01:29 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/
DIRECTOR:		VICTORINE, CHAYLENEFACILITY TYPE:
735
ADDRESS:699 COLLYER DRTELEPHONE:
(530) 244-7513
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY: 4CENSUS: 4DATE:
03/13/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Chaylene Victorine, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:40 PM
NARRATIVE
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03/13/2025 10:45 am Licensing Program Analysts (LPAs) Kayla Adkison and Sarah Benson arrived at the facility unannounced to conduct a Required-1 Year inspection. LPAs met with administrator Chaylene Victorine (cert #7008757735 exp.01/28/2026) and explained the purpose of the visit. Administrator certificate is current.

LPAs and administrator toured the facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to four (4) resident rooms, common areas, two (2) bathrooms, kitchen, garage, laundry room, and back yard. In the areas toured no immediate health, safety, or personal rights violations were observed. Staff and resident files were reviewed. Medications were also reviewed. Medication is locked in a locked cabinet.



The common area was clean, odor-free and in good repair. All bedrooms had required furniture, bedding, and lighting. The bathrooms were clean and in good repair. The kitchen was clean and in good repair. Cooking/dining equipment and utensils were present. Food appears to be stored and prepared properly. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food.
The facility was observed to be at a comfortable temperature. Fire extinguisher fully charged. Smoke detectors are all operational. Hot water temperature measured within required Title 22 regulations of 105 degrees F and 120 degrees F. All employees requiring background checks are cleared. There is a schedule of activities planned for the clients. All required postings are displayed within the facility.
No pools/bodies of water are on the premises. No firearms are on premises. The last disaster drill was conducted and documented on 12/28/24, the facility has been conducting drills every 3 months.

LPA interviewed one of one resident and one staff.

Citations were issued. Exit interview conducted and copy of report and appeal rights were provided to administrator. See attached 809-D.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Kayla Adkison
LICENSING EVALUATOR SIGNATURE: DATE: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2025
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 3
Document Has Been Signed on 03/13/2025 01:29 PM - It Cannot Be Edited


Created By: Kayla Adkison On 03/13/2025 at 12:47 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: COLLYER HOME
FACILITY NUMBER: 455002607

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in two cleaning products were accesible to residents under the sink in the kitchen area which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/20/2025
Plan of Correction
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Administrator removed cleaning products and stored them unaccesible to clients.
Staff training to keep cleaning products/poisons unaccessible to residents.
Administrator will notify LPA when complete.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Lauren Crocker
LICENSING EVALUATOR NAME:Kayla Adkison
LICENSING EVALUATOR SIGNATURE:
DATE: 03/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2025


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 03/13/2025 01:29 PM - It Cannot Be Edited


Created By: Kayla Adkison On 03/13/2025 at 12:47 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: COLLYER HOME
FACILITY NUMBER: 455002607

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80022(e)(4)
Plan of Operation
(e) If the licensee intends to admit or care for one or more clients who rely upon others to perform all activities of daily living, the plan of operation must also include a statement that demonstrates the licensee's ability to care for these clients. The evidence of ability may include but not be limited to: (4) Documentation of training the licensee and/or staff have completed specific to the needs of these clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 2 out of 2 staff files had outdated training logs which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/01/2025
Plan of Correction
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Staff will complete training for the ability to care for residents in need.
Adminstrator will conduct monthly review of staff files
Administrator will notify LPA when training is complete.
Type B
Section Cited
CCR
85068.3(a)
Modifications to Needs and Services Plan
(a) The written Needs and Services Plan specified in Section 85068.2 shall be updated as frequently as necessary to ensure its accuracy, and to document significant occurrences that result in changes in the client's physical, mental and/or social functioning.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, and record review, the licensee did not comply with the section cited above in three out of four needs and services plans were not current which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/20/2025
Plan of Correction
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Adminstrator will collect all updated needs and services plans and will update resident files.
Training will be conducted to additional staff on file review and update.
Administrator will notify LPA when training is complete.
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:Lauren Crocker
LICENSING EVALUATOR NAME:Kayla Adkison
LICENSING EVALUATOR SIGNATURE:
DATE: 03/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2025


LIC809 (FAS) - (06/04)
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