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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 585002452
Report Date: 08/20/2021
Date Signed: 08/20/2021 02:02:56 PM

Document Has Been Signed on 08/20/2021 02:02 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
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: 19DATE:
08/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Dorothy Davis; Program ManagerTIME COMPLETED:
02:30 PM
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On 8/20/21 at 12 PM, Licensing Program Analyst (LPA) Cheng conducted an unannounced required 1-year annual inspection and met with Program Manager Dorothy Davis. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted Administrator and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask and gloves. Additionally, LPA was screened by staff.

LPA Cheng toured the facility inside and out including but not limited to facility front entrance, activity room, bathrooms, art area, outside area, storage area, and kitchen. All passageways are free of obstruction. All staff and clients were observed to be wearing surgical mask. Facility entrance is equipped with proper COVID-19 signage and screening station. All smoke detectors were observed to be operational and fire extinguishers were observed as full. Facility has a designated area for clients should they become ill or show symptoms of COVID.

On 8/20/21 at 1PM, LPA Cheng along with Program Manager Dorothy Davis completed the infection the control domain with no issues noted.

No deficiency observed.

Exit interview conducted and a copy of report was given.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Pheej Cheng
LICENSING EVALUATOR SIGNATURE: DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2021
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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