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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 525001346
Report Date: 01/21/2025
Date Signed: 01/21/2025 11:26:05 AM

Document Has Been Signed on 01/21/2025 11:26 AM - 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:COFFMAN HOME IIFACILITY NUMBER:
525001346
ADMINISTRATOR/
DIRECTOR:
LYFORD, JULIEFACILITY TYPE:
735
ADDRESS:280 AGUA VERDE ROADTELEPHONE:
(530) 949-1891
CITY:RED BLUFFSTATE: CAZIP CODE:
96080
CAPACITY: 2CENSUS: 2DATE:
01/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Ann Coffman - licenseeTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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01/21/2025 09:45 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with licensee Ann Coffman 7028048735 exp. 08/08/2026 and care staff Amy Coffman and explained the purpose of the visit.

LPA Knight and the administrator toured the facility together to ensure the health and safety of clients in care. Areas toured include but are not limited to two (2)client rooms, common areas, two (2) bathrooms, kitchen, storage areas and back yard. Staff and resident files were reviewed. All employees requiring background checks are cleared.

Bedding, linens, and towels for clients were observed and found to be clean and in good repair. There is an adequate supply of toiletries for the clients. Medication is locked in a cabinet.

The facility was observed to be at a comfortable temperature. Common area was clean and in good repair. All bedrooms had required furniture, bedding, and lighting. Bathrooms were clean and in good repair. Kitchen was clean and in good repair. Food appears to be stored and prepared properly. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food. Fire extinguishers fully charged. There is a pool in the backyard that has a hard cover on the top which bears the weight of adults, the cover is only removed when the pool is in use. Last disaster drill was conducted in December 2025 which was a fire drill, the facility has been conducting fire drills every 3 months. Recreational activities are provided to meet the client's desires and abilities.

LPA requested an updated LIC308 Designation of facility responsibility.

In the areas toured no immediate health, safety, or personal rights violations were observed. No deficiencies are being cited as a result of today’s inspection.

Exit interview conducted and copy of report was provided to licensee Ann Coffman.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE: DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/21/2025
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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