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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 585002452
Report Date: 10/11/2022
Date Signed: 10/11/2022 11:05:39 AM

Document Has Been Signed on 10/11/2022 11:05 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 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: 11DATE:
10/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Michelle HillTIME COMPLETED:
11:15 AM
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LPA Hiratsuka, conducted this unannounced annual visit. LPA met with staff member Michelle Hill. LPA wore a surgical mask during visit.

This facility is a day program. Fire clearance is for ambulatory only. The building is surrounded by a fence on three sides and the main entrance to the building is inside the gated area. The gated area is not locked during business hours. Inside the gated area is fenced-in area for chickens. There is one shed and another small building used for storage in the gated area. The main entrance opens to a small foyer. To the left of the main entrance is a very short hallway that leads to a half-bathroom. Past the foyer is the main common area. There is a small creation station area to the left past the hallway that leads to a second half-bathroom. To the right has the kitchen. There is an office area on the back wall. The main common area has a stage. There is also a doorway on the left side of the stage when facing it leading to small storage and back door. Personal protective equipment supply was inspected as well. LPA observed all staff working wearing either paper surgical masks or N95 respirators.

Facility operating hours at this time are Monday through Friday 8:00am to 2:00pm and may change depending on the circumstances of what is happening.


A few topics were discussed during this visit.

No deficiencies cited.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2022
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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