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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804191
Report Date: 03/08/2024
Date Signed: 03/08/2024 12:20:36 PM

Document Has Been Signed on 03/08/2024 12:20 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:FARMSTEAD AT DIXON, THEFACILITY NUMBER:
486804191
ADMINISTRATOR:REYES, ALANAFACILITY TYPE:
740
ADDRESS:350 GATEWAY DRIVETELEPHONE:
(707) 592-1157
CITY:DIXONSTATE: CAZIP CODE:
95620
CAPACITY: 86CENSUS: 10DATE:
03/08/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Mark Reyes, AdministratorTIME COMPLETED:
12:25 PM
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Licensing Program Analysts (LPAs) Stefanie Mutialu and Jill Nakagawa arrived unannounced to conduct a Post Licensing Inspection. LPAs met with Mark Reyes, the newly-appointed Administrator. There are currently 10 residents in care.

During today’s visit LPAs observed the following items:

· All exits were unobstructed
· First Aid kit complete and flashlights for emergency lighting
· Supply of linens, paper products, and hygiene supplies available
· Grab bars and non-slip treatments in resident showers
· Fire Extinguishers are current: charged and last serviced 8/10/23, Fire inspection was completed on 01/05/2024 and approves 76 non-ambulatory and 10 bedridden
· Administrator Certification (expires 05/15/2025); Required postings (Personal Rights, Emergency plan/numbers, CCLD complaint poster, Emergency Disaster Plan, Client personal rights and visitor policy).
· Water temperature was tested and within regulation of 105 to 120 degrees F
· Auditory devices observed operational
· Residents' medications are centrally stored and locked
· Food supplies were within regulation
· Facility records were reviewed for residents and staff
No deficiencies cited during today's inspection.
Exit interview conducted with Administrator.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2024
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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