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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 570303745
Report Date: 07/12/2022
Date Signed: 07/12/2022 12:16:49 PM

Document Has Been Signed on 07/12/2022 12:16 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: 10DATE:
07/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Ashley Murillo, Program Assistant and
Katrina Brass, QIC		TIME COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct an Annual Inspection, focusing on Covid-19 Protocols and Practices. LPA was met outside by a Lead Staff who had LPA take a Covid test prior to entry to the facility. All visitors, essential visitors, and staff are screened upon entry and temperatures are taken. Facility was found to be clean, orderly, and at a comfortable temperature with all exits free from obstruction. Toxins are stored in locked cabinets. There was a sufficient supply of hygiene products, cleaners, and paper products for use as needed. Medications were stored and locked in a small med room making them inaccessible to residents and staff that do not handle medications. All bathrooms had soap and paper towels. All Covid-19 postings were up and visible to all as required. Facility has a sufficient supply of personal protective equipment (PPE). All staff had a mask on during the LPA's inspection. Mitigation plan was approved by the Department on 07/15/2021. Infection Control Plan was received by the Department on 06/30/2022.
There were ten (10) residents in care at the facility during this inspection.

No deficiencies during today's inspection.
No citations issued.
Exit interview conducted with the Ashley Murillo
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2022
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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