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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 570303745
Report Date: 01/26/2022
Date Signed: 04/27/2022 01:29:27 PM

Document Has Been Signed on 04/27/2022 01:29 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:FARMHOUSE, THEFACILITY NUMBER:
570303745
ADMINISTRATOR:ELIZABETH HALLFACILITY TYPE:
772
ADDRESS:24321 COUNTY ROAD 96TELEPHONE:
(530) 753-1653
CITY:DAVISSTATE: CAZIP CODE:
95616
CAPACITY: 10CENSUS: 9DATE:
01/26/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:42 AM
MET WITH:Elizabeth Hall, AdministratorTIME COMPLETED:
12:55 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to meet with Elizabeth Hall, Administrator regarding a Case Management- Incident Report at approximately 10:42 AM on 01/26/22. The inspection is being conducted to review client's incident report to determine the safety of medication administration at the facility.

LPA conducted an incident report review of client medication errors: 1 medication error; per conferencing with administration and review of medication records, the licensee did not ensure that the client was administered the correct dosage of a medication on 01/11/22.

Deficiencies cited from the California Code of Regulations (CCRs), Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 01/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2022
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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Document Has Been Signed on 04/27/2022 01:29 PM - It Cannot Be Edited


Created By: Jill Nakagawa On 01/26/2022 at 11:43 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: FARMHOUSE, THE
FACILITY NUMBER: 570303745

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/26/2022
Section Cited
CCR
80075(b)(5)(B)

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80075(b)(5)(B) Health Related Services. Medications shall be given according to physician's directions.

This requirement is not met as evidenced by:
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Licensee/administrator will review/retrain staff involved in the medication error by 02/02/22. Licensee will submit a summary of the training and provide an attendance record with participant signatures and send to CCL no later than 02/02/22.
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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:Kimberley Mota
LICENSING EVALUATOR NAME:Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2022


LIC809 (FAS) - (06/04)
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