<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804191
Report Date: 06/03/2024
Date Signed: 06/03/2024 11:44:55 AM

Document Has Been Signed on 06/03/2024 11:44 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
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) 592-1157
CITY:DIXONSTATE: CAZIP CODE:
95620
CAPACITY: 86CENSUS: DATE:
06/03/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Mark Reyes, AdmnistratorTIME VISIT/
INSPECTION COMPLETED:
11:40 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 (LPAs) Macias and Nakagawa arrived unannounced to conduct a case management visit regarding
an incident that was reported by the Administrator pertaining to resident (R1) who eloped from the facility on May 15, 2024.

During the course of the investigation record review of resident's files, facility records, and observations were made. The Department concluded that the facility did not meet the responsibility for providing care and supervision to R1. Title 22 regulation states that, the licensee shall provide Safety measures to address behaviors such as wandering, as identified in the resident's needs and services plan. According to the Physician's Report from 01/19/2024, R1 had a diagnosis of dementia and unable to leave facility unassisted The Needs and Services Plan states that R1 needed ongoing redirection due to frequent elopement risk. On May 15, 2024 R1 left the facility unassisted and was not discovered until the 8 PM Medication administration. Resident was recovered unharmed by police, staff and family at 8:15 PM approximately 1/2 mile down the street.

The following deficiencies were 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: 06/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/03/2024
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 2
Document Has Been Signed on 06/03/2024 11:44 AM - It Cannot Be Edited


Created By: Jill Nakagawa On 06/03/2024 at 11:04 AM
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: 06/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/03/2024
Section Cited
CCR
87705(b)(2)

1
2
3
4
5
6
7
87705(b)(2) Care of Persons with Dementia: Safety measures to address behaviors such as wandering. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Administrator agrees to conduct staff training regarding elopement, wandering and ensuring that all exterior doors are alarmed and monitored.
8
9
10
11
12
13
14
 Based on self-reported incident report the facility didn't comply with this section for resident (R1) , who left facility unattended which poses an immediate Health and Safety risk.
8
9
10
11
12
13
14
A plan of correction to be submitted to CCL by 6/4/2024.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 06/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/03/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2