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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 570303745
Report Date: 04/28/2023
Date Signed: 04/28/2023 04:29:28 PM

Document Has Been Signed on 04/28/2023 04:29 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:
04/28/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Ashley Murillo, Assistant AdministratorTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to meet with Ashley Murillo, assistant administrator regarding a Case Management- Incident Report at approximately 4:00 PM on 04/28/2023. The inspection is being conducted to review client's incident report of 03/26/2023 to determine the safety of medication administration at the facility.

LPA conducted an incident report review of client medication error with Assistant Administrator Ashley Murillo (AM). AM reported that the facility has put new protocols in place to ensure medications are administered correctly. The facility is using a "Buddy System", where two staff work together to double-check accuracy of medication administration. in addition, the Administrator is using a new Calendar System, which posts med times on staff/facility mobile phone and staff computer (which remains in office and for staff use only). Per conferencing with administration the licensee will ensure that clients are administered the correct dosage of a medication

No citation issued..
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2023
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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