486804191-9-27-2024-21-AS-KMOA-D9NUBB-20241002152603

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486804191
Report Date: 09/27/2024
Date Signed: 09/27/2024 10:41:53 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/28/2024 and conducted by Evaluator Jill Nakagawa

COMPLAINT CONTROL NUMBER: 21-AS-20240528151013

FACILITY NAME:	FARMSTEAD AT DIXON, THE		FACILITY NUMBER:	486804191
ADMINISTRATOR:	MARK REYES		FACILITY TYPE:	740
ADDRESS:	350 GATEWAY DRIVE		TELEPHONE:	(707) 592-1157
CITY:	DIXON	STATE: CA	ZIP CODE:	95620
CAPACITY:	96	CENSUS: 38	DATE:	09/27/2024
		UNANNOUNCED	TIME BEGAN:	09:55 AM
MET WITH:	Mark Reyes, Administrator		TIME COMPLETED:	10:41 AM

ALLEGATION(S):

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Staff mismanaged residents’ medications.
Staff did not maintain accurate medication records for residents.
Staff did not report incidents involving residents as required.
Staff did not appropriately evaluate residents’ service needs.
Staff did not provide adequate supervision resulting in a resident wandering away from the facility.

INVESTIGATION FINDINGS:

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The complaint alleges that staff mismanaged residents’ medications and staff did not maintain accurate medication records for residents. Through interviews LPA learned that staff had been informed by management to document inaccurate information on the MAR. LPA reviewed documents and conducted interviews with staff and found no irregularities in the MARs. A random check of medications found no discrepancies and all medications appeared to have been given as prescribed. LPA could find no evidence to corroborate the allegations therefore they allegations are unsubstantiated. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated

Continued on 9099-C......

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20240528151013

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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, THE	FACILITY NUMBER: 486804191
	VISIT DATE: 09/27/2024

NARRATIVE

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Continued from 9099...

LPA investigated the allegation that staff did not provide adequate supervision resulting in resident (R1) attempting to wander away from the facility. LPA conducted interviews and reviewed records. A review of R1’s current medical records show that R1 is able to leave the facility unassisted. In addition, a review of records does not show that R1 was ever at risk outside of the facility. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

LPA investigated the allegation that Staff did not report incidents involving residents as required. The reporting party cited incident, which occurred on 5/15/2024, believed to have gone unreported. LPA found Administrator did report incidents which required reporting to Community Care Licensing (CCL) within the timeframe specified in regulation; including the incident involving Resident R2 leaving the facility on 5/15/2024 and reported to CCL on 5/16/2024. LPA could find no evidence of incidents which have not been reported per regulations. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation that staff did not report incidents involving residents as required is unsubstantiated.

The complaint alleges Staff did not appropriately evaluate residents’ service needs. LPA conducted interviews and reviewed records. All records were found to be up to date and assessments completed per regulations based on information provided to the facility. Record reviews revealed that facility made appropriate changes in care plans when additional information was obtained timely. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024

LIC9099 (FAS) - (06/04)

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