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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 585002452
Report Date: 05/14/2025
Date Signed: 05/14/2025 02:13:30 PM

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
05/12/2025 and conducted by Evaluator Kerry Hiratsuka
COMPLAINT CONTROL NUMBER: 59-AS-20250512145220
FACILITY NAME:FARM TO FORKFACILITY NUMBER:
585002452
ADMINISTRATOR:SHAUNA HERMANFACILITY TYPE:
775
ADDRESS:931 RAMIREZ STREETTELEPHONE:
(530) 645-7648
CITY:MARYSVILLESTATE: CAZIP CODE:
95901
CAPACITY:30CENSUS: 21DATE:
05/14/2025
UNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Amber DupuisTIME COMPLETED:
02:20 PM
ALLEGATION(S):
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Facility is in disrepair
Facility does not have an administrator
INVESTIGATION FINDINGS:
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LPA HIratrsuka conducted the investigation into the allegations above.

LPA toured the facility. The issues do not pose immediate threat to the clients. The following was observed:
-There are multiple leaks in the roof. The most current one is in the storage area to the left of the main entrance that also has a half bathroom. The leak in the roof is right next to a light fixture in the ceiling. There are also several areas in the main common area that have water stains and paint peeling on the celing indicating leaks.
-The client half bathroom does not have cold water.
-The kitchen has several electrical outlets that don't work.
-There are two holes in the wall inside the building on the right side next to the double doors.
-The staff half bathroom has a gap in the wall.
--There is a hole in the window next to the main entrance.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2025
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 4
Control Number 59-AS-20250512145220
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: 05/14/2025
NARRATIVE
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-When facing the main entrance, walking on the walkway on the right side of the building, there is some kind of growth coming out of wood wall. There is damage to those wood panels because when touched the wood was not solid and made a crunchy sound.
-When facing the main entrance, walking on the walkway on the right side of the building, there is a broken window that is the last one on the right side of the building. There is a hole in the double pane window. The inside pane is not broken, only the outside.
-The bricks are stained in the client bathroom and staff break room. LPA was given information that it is mold.

Licensee is to hire licensed, professional workers to address the issues above.

The facility does not have an administrator. The administrator on record hasn't worked at this facility for several months. Licensee has not appointed a new one. LPA was informed there is a program manager, but the administrator on record is no longer the 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. Appeal rights left.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 59-AS-20250512145220
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: 05/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/21/2025
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 05/21/2025, the licensee shall appoint an administrator.
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Based on observation and interviews the administrator on records hasn't worked as the administrator for several months. this poses a potential health and safety risk to clients.
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Type B
05/28/2025
Section Cited
CCR
82087(a)
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Buildings and Grounds. The program site shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. Based on observation it was determined that the licensee failed to ensure the roof does not leak, electrical outlets work, did not
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By 05/28/2025, Licensee shall submit contracts from licensed, professional contractors who shall perform repairs. The licensee shall also submit a written plan on how they shall ensure the clients are not disturbed when the repairs are done.
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repair holes in broken windows, preventing growth in the wood on the side of the bulding, and more. This poses a potential health and safety risk to clients in care.
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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: 05/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4