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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486804191
Report Date: 10/20/2025
Date Signed: 10/20/2025 05:02:05 PM

Substantiated


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
09/02/2025 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20250902171844
FACILITY NAME:FARMSTEAD AT DIXON, THEFACILITY NUMBER:
486804191
ADMINISTRATOR:MARK REYESFACILITY TYPE:
740
ADDRESS:350 GATEWAY DRIVETELEPHONE:
(707) 676-5060
CITY:DIXONSTATE: ZIP CODE:
95620
CAPACITY:96CENSUS: 74DATE:
10/20/2025
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Mark Reyes, Administrator and Maribel Samayoa, Resident Care CoordinatorTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Staff is not following resident's special diet
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Nakagawa arrived unannounced on 10/20/2025 to conclude an investigation and deliver findings regarding the allegation listed above and met with Mark Reyes, Administrator and Maribel Samayoa to discuss.
The complaint alleges that Staff is not following resident's special diet. The complainant stated that the resident’s (R1) responsible party checked R1’s camera and saw that someone had brought R1 a plate of shrimp for dinner and told complainant. Complainant stated that R1 is allergic to shrimp and it is listed in more than one place on Farmstead’s records.
(Continued on 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 21-AS-20250902171844
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: 10/20/2025
NARRATIVE
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(Continued from 9099)

 LPA reviewed the records for R1 and found that the Physician’s Report dated 4/29/2025 states the section for allergies says  “See Attached”.   Staff was unable to find the “attached” list; and staff did not follow up with doctor’s office to verify R1’s allergies, however the pre-appraisal, resident assessment and care plan for R1 all list R1’s allergy to shellfish/shrimp.  A list of residents and their allergies is posted in the med room for care staff to check which includes R1 and their allergy to shrimp. According to the Administrator there is a list in the kitchen with pictures of the residents and their allergies and it is the dietary staff’s responsibility to review the list before serving.  Interviews with R1, Staff (S1)  and  Staff (S2) confirmed that R1 was served shrimp which was not part of their special diet.  Staff S2 reported the resident did not eat the shrimp and staff was able to retrieve the food and bring R1 a meal within R1’s special diet. Based on LPA’s observations, review of records and interviews conducted, the preponderance of evidence standard has been met, therefore the allegation that Staff is not following R1’s special diet is found to be SUBSTANTIATED.  California Code of Regulations, (Title 22, Division 6 & Chapter 8), is being cited on the attached LIC 9099D.
Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
 
Exit interview conducted. Copy of report, LIC-9099-D, Plan of Corrections and Appeal Rights discussed and provided to Administrator Mark Reyes. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20250902171844
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/20/2025
Section Cited
CCR
87555(b)(7)
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87555(b)(7)General Food Service Requirements.Modified diets prescribed....resident's physician... shall be provided. Based on documents and statements of individuals, this requirement has not been met as evidenced by:
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Administrator shall provide a written plan that outlines how facility will ensure that special diets are served to residents when ordered by physician.
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staff did not follow diet prescribed by R1's physician nor listed in R1's care plan. This posed an immediate risk to the health, safety and personal rights to persons in care.
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Administrator to provide the list of residents and and their allergies usd by kitchen and care staff. Plan and list has been submitted to LPA on 10/20/2025 to clear the POC during LPA's visit.
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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.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3