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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 570303745
Report Date: 08/15/2023
Date Signed: 09/05/2023 12:05:43 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/18/2023 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20230718143605
FACILITY NAME:FARMHOUSE, THEFACILITY NUMBER:
570303745
ADMINISTRATOR:ASHLEY MURILLOFACILITY TYPE:
772
ADDRESS:24321 COUNTY ROAD 96TELEPHONE:
(530) 753-1653
CITY:DAVISSTATE: CAZIP CODE:
95616
CAPACITY:10CENSUS: DATE:
08/15/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Ashley Murillo, AdministratorTIME COMPLETED:
10:05 AM
ALLEGATION(S):
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Facility staff makes inappropriate comments while caring for residents.
INVESTIGATION FINDINGS:
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*This is amended version of original signed on 8/15/23.

Licensing Program Analyst (LPA) Nakagawa arrived unannounced to complete investigation and deliver findings regarding the above allegation.

It is alleged “a staff member who makes people uncomfortable with their comments and body language”. LPA conducted interviews with staff and residents in care, reviewed records and made observations. Interviews revealed that Staff (S1) was heard making inappropriate comments by (S2) while in the presence of clients in care. Continued on 9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 21-AS-20230718143605
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: FARMHOUSE, THE
FACILITY NUMBER: 570303745
VISIT DATE: 08/15/2023
NARRATIVE
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Continued....

Based on LPA’s information gathered, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 & Chapter 2), are being cited on the attached LIC 9099D.”)
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20230718143605
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: FARMHOUSE, THE
FACILITY NUMBER: 570303745
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/15/2023
Section Cited
CCR
81072(a)(1)
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81072 (a)(1) Personal Rights(a) Each client shall have personal rights…..(1)to be accorded dignity in his /her personal relationships… This requirement is not met as evidenced by:
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Facility administrator agrees to submit proof that staff have been re-trained in the personal rights...
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Based on interviews, record review the licensee did not comply with the section cited which poses a possible risk to the health, safety or personal rights risk to persons in care.
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of the individuals working and residing in this facility and understanding HIPPA to LPA by 8/21/2023.
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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.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3