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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 570303745
Report Date: 01/06/2022
Date Signed: 01/06/2022 02:36:38 PM

Document Has Been Signed on 01/06/2022 02:36 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
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:
01/06/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Elizabeth Hall, AdministratorTIME COMPLETED:
02:30 PM
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Licensing Program Analyst Jill Nakagawa arrived unannounced to go over SIRs at The Farmhouse regarding AWOL and medication not being refilled in a timely manner. LPA met with Elizabeth Hall, Administrator, and discussed the situations that resulted in the SIRs.

The AWOL was a combination of several situations that culminated in the resident leaving the facility due to manic episode. Resident was located, taken to PCP, and received necessary treatment and therapy which has resulted in no further behaviors or complications.

The medication error was explained and although the medication did not arrive in time, it was actually ordered in a timely fashion, but due to the holidays it was not received in time. PCP was notified of the situation and no need for medical treatment was necessitated, via PCP. Resident did not have any concerns over the situation.

There were 9 residents in care at the facility during this inspection.

No deficiencies during today's inspection.
No citations issued.
Exit interview conducted with the Administrator.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 01/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/06/2022
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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