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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 585002452
Report Date: 10/30/2024
Date Signed: 10/30/2024 11:34:12 AM

Document Has Been Signed on 10/30/2024 11:34 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 FORKFACILITY NUMBER:
585002452
ADMINISTRATOR/
DIRECTOR:		SHAUNA HERMANFACILITY TYPE:
775
ADDRESS:931 RAMIREZ STREETTELEPHONE:
(530) 645-7648
CITY:MARYSVILLESTATE: CAZIP CODE:
95901
CAPACITY: 30CENSUS: 27DATE:
10/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Amber Dupuis and Shauna HermanTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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LPA Hiratsuka and Mikkelson, conducted this unannounced annual visit. LPAs met and toured the facility with Amber Dupruis and then Program Manager Shauna Herman joined during the 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 has a 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 staff storage area to the left past the hallway that leads to a second half-bathroom. To the right has the kitchen. 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. There is an office to the right of the stage when facing it that locks and stores all confidential files.

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.

Multiple topics were discussed during this visit. Reminded facility to write down emergency fire drill log when completed and maintain fire extinguishers in facility.

No deficiencies cited.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2024
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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