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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 525001346
Report Date: 02/06/2023
Date Signed: 02/07/2023 02:11:17 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 02/07/2023 02:11 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
CCLD Regional Office,
, CA
FACILITY NAME:COFFMAN HOME IIFACILITY NUMBER:
525001346
ADMINISTRATOR:LYFORD, JULIEFACILITY TYPE:
735
ADDRESS:280 AGUA VERDE ROADTELEPHONE:
(530) 949-1891
CITY:RED BLUFFSTATE: CAZIP CODE:
96080
CAPACITY: 2CENSUS: 2DATE:
02/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:ANN COFFMAN - LICENSEETIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced Required 1 Year Inspection Visit utilizing the infection control domain. LPA met with licensee and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPA Wallace was screened by licensee.

LPA Wallace and licensee toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, two (2) resident bedrooms, two (2) bathrooms, kitchen, and storage areas. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA Wallace and the licensee completed the infection control domain and facility was found to be in substantial compliance at this time.

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

Exit interview conducted and copy of report was given to licensee.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 02/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/06/2023
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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