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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 525001971
Report Date: 03/02/2022
Date Signed: 03/02/2022 02:26:31 PM

Document Has Been Signed on 03/02/2022 02:26 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:ADOBE RESIDENTIAL GILMOREFACILITY NUMBER:
525001971
ADMINISTRATOR:ERICKSEN, DARRICKFACILITY TYPE:
735
ADDRESS:85 GILMORE ROADTELEPHONE:
(530) 529-5380
CITY:RED BLUFFSTATE: CAZIP CODE:
96080
CAPACITY: 4CENSUS: 4DATE:
03/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Darrick Ericksen - administratorTIME COMPLETED:
02:45 PM
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03/02/2022 1:45 PM Licensing Program Analysts (LPAs) Rebecca Knight at the facility unannounced to conduct a Required-1 Year Inspection utilizing the infection control domain, LPAs met with administrator Darrick Ericksen and explained the purpose of the visit. Prior to initiating the annual inspection, LPAs completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted administrator and completed a facility risk assessment. LPAs ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 Mask, gloves.

LPA Knight and Mr. Ericksen 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, two (2) bathrooms, kitchen, storage areas. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA Knight and the administrator 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 todays inspection. Technical assistance was provided.

Exit interview conducted and copy of report was emailed to administrator Darrick Ericksen.
SUPERVISORS NAME: Rayna L Bryson
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE: DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/02/2022
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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