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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 585002452
Report Date: 01/30/2024
Date Signed: 01/30/2024 11:40:16 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/06/2023 and conducted by Evaluator Kerry Hiratsuka
COMPLAINT CONTROL NUMBER: 59-AS-20231206153403
FACILITY NAME:FARM TO FORKFACILITY NUMBER:
585002452
ADMINISTRATOR:VAN BUSKIRK, MATTFACILITY TYPE:
775
ADDRESS:931 RAMIREZ STREETTELEPHONE:
(530) 645-7648
CITY:MARYSVILLESTATE: CAZIP CODE:
95901
CAPACITY:30CENSUS: 20DATE:
01/30/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Shauna HermanTIME COMPLETED:
11:50 AM
ALLEGATION(S):
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1. Facility is in disrepair
2. Facility does not have a qualified director
INVESTIGATION FINDINGS:
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LPA Hiratsuka conducted this visit to deliver the results of the investigation above. LPA met with Program Manager Shauna Herman.

During the investigation the program manager, staff, and witnesses interviewed. A tour of the facility was conducted on 12/13/2023.

1. Site Manager stated there are issues with the roof and it sometimes will leak when it rains. The leaks are fixed when they are discovered. She stated they are in the process of getting bids to change the roof. When a leak is discovered, something is placed under the leak and the area is taped off until it can be fixed. Because the roof leaks sometimes, the allegation is substantiated.


Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
Control Number 59-AS-20231206153403
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: FARM TO FORK
FACILITY NUMBER: 585002452
VISIT DATE: 01/30/2024
NARRATIVE
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2. Per Title 22 regulations regarding adult day programs, 82064(g) Administrator - Qualifications and Duties The administrator shall be at the program site the number of hours necessary to manage and administer the program in compliance with applicable laws and regulations. LPA was informed the administrator is not living in California and does not visit the facility and is only available by mobile device and email. The licensee did appoint a site manager, but the person is not designated as the facility administrator.

Based on the evidence obtained, the preponderance of evidence standard has been met, therefore the allegation is found to be substantiated. The following deficiency was cited per CA Code of Regulations Title 22- refer to the 9099-D.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 59-AS-20231206153403
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: FARM TO FORK
FACILITY NUMBER: 585002452
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/01/2024
Section Cited
CCR
80087(a)
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Buildings and Grounds. The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
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By 03/01/2024, the licensee shall submit in writing how they shall monitor the roof and what the plans are to keep it safe.
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Based on observation and interview it was determined that the licensee failed to ensure the roof does not leak This poses a potential health and safety risk to clients in care.
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Type B
03/01/2024
Section Cited
CCR
82064(g)
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Administrator - Qualifications and Duties The administrator shall be at the program site the number of hours necessary to manage and administer the program in compliance with applicable laws and regulations.
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By 03/01/2024, the licensee shall appoint an administrator.
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Based on observation and interviews the administrator is not on site and living in another state.
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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.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/06/2023 and conducted by Evaluator Kerry Hiratsuka
COMPLAINT CONTROL NUMBER: 59-AS-20231206153403

FACILITY NAME:FARM TO FORKFACILITY NUMBER:
585002452
ADMINISTRATOR:VAN BUSKIRK, MATTFACILITY TYPE:
775
ADDRESS:931 RAMIREZ STREETTELEPHONE:
(530) 645-7648
CITY:MARYSVILLESTATE: CAZIP CODE:
95901
CAPACITY:30CENSUS: 20DATE:
01/30/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Shauna HermanTIME COMPLETED:
11:50 AM
ALLEGATION(S):
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2
3
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5
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9
 Facility is operating out of ratio
INVESTIGATION FINDINGS:
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LPA Hiratsuka conducted this visit to deliver the results of the investigation above. LPA met with Program Manager Shauna Herman.

The interviews indicate there are four clients who require one-to-one supervision. The interviews state there are times where the assigned staff member to the client(s) will call-out of work with little to no notice and the person in charge will start calling other staff to come to work to fill in the client(s) who requires one-to-one supervision. Interviews also state there have been times where there was enough staff in the beginning of shift but the a staff member who is assigned to a client who is one-to-one supervision will leave due to an emergency and depending on the time a substitute will be sought and in a couple of cases the client was sent home.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 59-AS-20231206153403
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: FARM TO FORK
FACILITY NUMBER: 585002452
VISIT DATE: 01/30/2024
NARRATIVE
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Due to the information gathered, LPA cannot determine the allegations: Facility is operating out of ratio. LPA finds allegation to be unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are unsubstantiated.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 7