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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 525001971
Report Date: 02/18/2025
Date Signed: 02/18/2025 11:23:46 AM

Document Has Been Signed on 02/18/2025 11:23 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:ADOBE RESIDENTIAL GILMOREFACILITY NUMBER:
525001971
ADMINISTRATOR/
DIRECTOR:		ERICKSEN, DARRICKFACILITY TYPE:
735
ADDRESS:85 GILMORE ROADTELEPHONE:
(530) 529-5380
CITY:RED BLUFFSTATE: CAZIP CODE:
96080
CAPACITY: 4CENSUS: 4DATE:
02/18/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Darrick Ericksen - administratorTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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02/18/2025 09:45 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with administrator DarrIck Ericksen ( cert. 7001936735 exp 04/09/2025) and explained the purpose of the visit.

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. Staff and resident files were reviewed.

Common area, kitchen, and bathrooms were clean and in good repair. All bedrooms had required furniture, bedding, and lighting. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food. Medication is locked in a cabinet.

First aid kit fully stocked and ready for emergency use. Fire extinguishers fully charged and inspected. Smoke detectors are all operational. All employees requiring background checks are cleared.

No pools/bodies of water are on premises. The facility has been conducting emergency evacuation drills every quarterly.

A deficiency is being cited as a result of today’s inspection and is documented on the attached LIC809-D. One client room has a leaky window that needs to be caulked and there are stained ceiling tiles indicating that a possible roof leak occurred at some point since the last annual inspection.



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: 02/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/18/2025
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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Document Has Been Signed on 02/18/2025 11:23 AM - It Cannot Be Edited


Created By: Rebecca Knight On 02/18/2025 at 10:56 AM
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: ADOBE RESIDENTIAL GILMORE
FACILITY NUMBER: 525001971

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in 1 of 4 client rooms which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/11/2025
Plan of Correction
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Licensee agrees to hire a licensed roofing inspector to determine whether the roof need repair or just the ceiling tiles need to be replaced. Licensee shall submit a plan to LPA after the roof inspection has been completed with plan for repair of roof and / or replacement of ceiling tiles. Licensee shall complete the caulking of the leaking window and submit a photograph to LPA as proof of correction.
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:Rebecca Knight
LICENSING EVALUATOR SIGNATURE:
DATE: 02/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/18/2025


LIC809 (FAS) - (06/04)
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