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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 525001971
Report Date: 04/24/2023
Date Signed: 04/24/2023 10:55:26 AM

Document Has Been Signed on 04/24/2023 10:55 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
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:
04/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:22 AM
MET WITH:DarrIck Ericksen - administratorTIME COMPLETED:
11:00 AM
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04/24/2023 09:20 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with administrator DarrIck Ericksen ( 6007124735 exp. 04/09.2023 ) and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed a self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms.

LPA Knight and the 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, storage areas 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.

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. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food. Medication is locked in a kitchen cabinet.

Administrator certificate expired on 04/09/2023, the administrator has submitted all required paperwork for renewal and is waiting for their new certificate to be issued. First aid kit fully stocked and ready for emergency use. Fire extinguishers fully charged and were inspected in March 2023. Smoke detectors are all operational. All employees requiring background checks are cleared. All required postings are displayed within facility.

No pools/bodies of water are on premises. No firearms are on premises. Last disaster drill was conducted in February 2023 which was a fire drill. The facility has been conducting drills every 4 months.

No deficiencies are being cited as a result of today’s inspection. Technical assistance was provided.



Exit interview conducted and copy of report was provided to administrator DarrIck Ericksen
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE: DATE: 04/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/24/2023
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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