<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
585002452
Report Date:
03/20/2024
Date Signed:
03/20/2024 09:21:50 AM
Document Has Been Signed on
03/20/2024 09:21 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
SACRAMENTO NORTH ASC
,
9835 GOETHE ROAD, SUITE 100
SACRAMENTO
,
CA
95827
FACILITY NAME:
FARM TO FORK
FACILITY NUMBER:
585002452
ADMINISTRATOR:
VAN BUSKIRK, MATT
FACILITY TYPE:
775
ADDRESS:
931 RAMIREZ STREET
TELEPHONE:
(530) 645-7648
CITY:
MARYSVILLE
STATE:
CA
ZIP CODE:
95901
CAPACITY:
30
CENSUS:
18
DATE:
03/20/2024
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
09:00 AM
MET WITH:
Amber Dupuis
TIME COMPLETED:
09:25 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts Hiratsuka and Yang, conducted this unannounced case management visit. The purpose of this visit is to deliver an amended confidential report.
No deficiencies cited.
SUPERVISORS NAME
:
Troy Ordonez
LICENSING EVALUATOR NAME
:
Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE
:
DATE:
03/20/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/20/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
Page:
1
of
1