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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 570303745
Report Date: 04/25/2024
Date Signed: 04/25/2024 02:49:46 PM

Document Has Been Signed on 04/25/2024 02:49 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/
DIRECTOR:		ASHLEY MURILLOFACILITY TYPE:
772
ADDRESS:24321 COUNTY ROAD 96TELEPHONE:
(530) 753-1653
CITY:DAVISSTATE: CAZIP CODE:
95616
CAPACITY: 10CENSUS: 10DATE:
04/25/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Nate Harper, Assistant Program Manager
Jerome Olsson, 		TIME VISIT/
INSPECTION COMPLETED:
02:50 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct an inspection. 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.
The facility's grounds were found to be well cared, with lots of containers of flowers and vegetables.

There were 3 staff members on site, and ten (10) residents in care at the facility during this inspection.

In addition LPA Nakagawa amended the report from 04/09/2024.

No deficiencies cited.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2024
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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