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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804191
Report Date: 01/10/2025
Date Signed: 01/10/2025 04:55:43 PM

Document Has Been Signed on 01/10/2025 04:55 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/
DIRECTOR:		MARK REYESFACILITY TYPE:
740
ADDRESS:350 GATEWAY DRIVETELEPHONE:
(707) 676-5060
CITY:DIXONSTATE: CAZIP CODE:
95620
CAPACITY: 96CENSUS: 51DATE:
01/10/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:40 PM
MET WITH:Mark Reyes, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:55 PM
NARRATIVE
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On 01/10/2025, LIcensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to complete the Annual Inspection and met with Administrator Mark Reyes.

LPA Nakagawa completed the Care Tool as well as finished a physical tour of the facility. The kitchen and dining room were inspected while there was no meal service going on. LPA observed that the dining room was clean and sanitary and set up for the next meal service. Tableware was clean and tables included a small decoration. Menus are large and easy to read and diners enjoy tableside service.

LPA discussed medication management and documentation with the Administrator and new Resident Care Coordinator who will be overseeing the training of medication technicians going forward. Due to errors found in medication records and an incident report self-reporting a medication error a deficiency will be given (see 809-D).

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided to the Administrator.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 01/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/10/2025
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 3
Document Has Been Signed on 01/10/2025 04:55 PM - It Cannot Be Edited


Created By: Jill Nakagawa On 01/10/2025 at 04:01 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: FARMSTEAD AT DIXON, THE
FACILITY NUMBER: 486804191

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(4)
87465 Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall... provide for assistance in obtaining such care, by compliance with the following:(4) The licensee shall assist residents with self-administered medications as needed.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and self-reported incident report, the Licensee did not comply with the section cited above. Resident 1 (R1) did not receive a medication they had a doctor's order for. This poses an immediate health, safety or personal rights risk to residents in care.
POC Due Date: 01/13/2025
Plan of Correction
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Deficiency cleared during visit. LPA was provided with medication training documentation that was conducted 12/2024..
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Kimberley Mota
LICENSING EVALUATOR NAME:Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:
DATE: 01/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2025


LIC809 (FAS) - (06/04)
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