Inspection Report Summary
Most inspections found no deficiencies, including the most recent complaint investigation on September 23, 2025, which found no evidence to support allegations of staff violating residents' rights or improper assistance during transfers. Earlier reports identified some issues with medication management, including failures to assist residents with self-administered medications in January and August 2025, which posed immediate health risks and led to staff training. A substantiated complaint in June 2024 found inadequate supervision of a resident with dementia who eloped, representing the most serious safety concern in the record. Several complaint investigations were unsubstantiated, and other visits noted the facility was clean, well-maintained, and compliant with regulations. The trend shows improvement in recent months, with no deficiencies found in the latest inspections after earlier medication and supervision issues.
Deficiencies per Year
4
3
2
1
0
High
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 52
Capacity: 96
Deficiencies: 0
Sep 23, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2025-06-24 regarding staff violating residents' personal rights and improper assistance during resident transfers.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Interviews, document reviews, and observations indicated that staff had received required training and no complaints were found against the staff involved. No deficiencies or citations were issued.
Complaint Details
The complaint alleged that staff violated a resident's personal rights by pulling the resident's arm and threatening eviction, and that staff did not properly assist a resident during transfers resulting in a fall and fracture. Both allegations were found unsubstantiated after interviews, record reviews, and observations.
Report Facts
Capacity: 96
Census: 52
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jill Nakagawa | Licensing Program Analyst | Conducted the complaint investigation |
| Mark Reyes | Administrator | Facility administrator met during investigation |
| Kimberley Mota | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Follow-Up
Capacity: 96
Deficiencies: 1
Aug 14, 2025
Visit Reason
The inspection was an unannounced case management follow-up visit triggered by a self-reported incident involving a medication error that occurred on 2025-08-06.
Findings
The facility failed to comply with the requirement to assist residents with self-administered medications, as Resident 1 did not properly receive a medication ordered by a doctor, posing an immediate health and safety risk. Staff received medication training following the incident.
Complaint Details
The visit was complaint-related, following a self-reported incident of a medication error on 2025-08-06. The report indicates that the medication error was substantiated.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to assist residents with self-administered medications as required, resulting in Resident 1 not properly receiving a medication ordered by a doctor. | Type A |
Report Facts
Facility capacity: 96
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mark Reyes | Administrator | Met during inspection and involved in the medication error incident |
| Mirabel Samoya | Resident Care Coordinator | Conducted the inspection and involved in medication error incident |
| Jill Nakagawa | Licensing Program Analyst | Conducted the inspection and signed the report |
Inspection Report
Census: 77
Capacity: 96
Deficiencies: 0
Jul 1, 2025
Visit Reason
The visit was an unannounced case management visit to follow up on staff S1 and the status regarding an incident that occurred on 2025-06-23.
Findings
The Administrator conducted an internal investigation and disciplinary action against staff S1, including staff-wide training on resident personal rights. No deficiencies or citations were found at the time of the visit.
Report Facts
Incident date: Jun 23, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mark Reyes | Administrator | Met during inspection and conducted internal investigation and disciplinary action |
| Jill Nakagawa | Licensing Program Analyst | Conducted the case management visit |
| Mirabeal Samoya | Care Coordinator | Met during inspection |
Inspection Report
Annual Inspection
Census: 51
Capacity: 96
Deficiencies: 1
Jan 10, 2025
Visit Reason
The visit was an unannounced annual inspection conducted by Licensing Program Analyst Jill Nakagawa to evaluate compliance with regulations and assess facility conditions.
Findings
The inspection found the facility to be clean and well-maintained, with proper dining room setup and medication management training underway. However, a deficiency was cited due to medication errors, including a resident not receiving a prescribed medication, posing an immediate health risk.
Deficiencies (1)
| Description |
|---|
| Failure to assist residents with self-administered medications as required, evidenced by a resident not receiving a medication they had a doctor's order for. |
Report Facts
Capacity: 96
Census: 51
Plan of Correction Due Date: Jan 13, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mark Reyes | Administrator | Met with Licensing Program Analyst during inspection and discussed medication management |
| Jill Nakagawa | Licensing Program Analyst | Conducted the annual inspection and authored the report |
| Kimberley Mota | Licensing Program Manager | Named as Licensing Program Manager overseeing the inspection |
Inspection Report
Annual Inspection
Census: 51
Capacity: 96
Deficiencies: 0
Jan 2, 2025
Visit Reason
An unannounced annual inspection was conducted to evaluate compliance with licensing requirements at the Farmstead at Dixon facility.
Findings
The facility was found to be clean, well-maintained, and compliant with regulations. No citations were issued during the inspection. The facility provides ample social and recreational activities, and water temperatures were within required limits.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mark Reyes | Administrator | Met with Licensing Program Analyst during the inspection. |
| Jill Nakagawa | Licensing Program Analyst | Conducted the annual inspection. |
| Kimberley Mota | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 38
Capacity: 96
Deficiencies: 0
Sep 27, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-05-28 regarding medication mismanagement, inaccurate medication records, failure to report incidents, inadequate evaluation of residents' service needs, and inadequate supervision resulting in a resident wandering away.
Findings
The investigation found no evidence to substantiate the allegations. Medication records were accurate, medications were administered as prescribed, incidents were reported as required, residents' service needs were appropriately evaluated, and supervision was adequate. All allegations were determined to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint involved multiple allegations including medication mismanagement, inaccurate medication records, failure to report incidents, inadequate evaluation of residents' service needs, and inadequate supervision leading to a resident wandering away. All allegations were investigated and found unsubstantiated.
Report Facts
Facility capacity: 96
Census: 38
Complaint received date: May 28, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mark Reyes | Administrator | Met with during investigation and mentioned in findings |
| Jill Nakagawa | Licensing Program Analyst | Conducted the complaint investigation |
| Kimberley Mota | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Census: 33
Capacity: 96
Deficiencies: 0
Aug 13, 2024
Visit Reason
An unannounced case management visit was conducted to follow up on resident R1 and their medication management.
Findings
The Licensing Program Analyst observed that the facility staff were diligent in working with resident R1 to maintain a good rapport and high level of trust. There were no deficiencies found and no citations issued at the time of the visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mark Reyes | Administrator | Met with Licensing Program Analyst during the visit and involved in resident R1's care coordination. |
| Jill Nakagawa | Licensing Program Analyst | Conducted the unannounced case management visit. |
| Jolene Barnett | Care Coordinator | Worked closely with Administrator and resident R1's family and doctors. |
Inspection Report
Complaint Investigation
Capacity: 86
Deficiencies: 1
Jun 3, 2024
Visit Reason
The visit was an unannounced case management inspection triggered by an incident reported by the Administrator regarding a resident (R1) who eloped from the facility on May 15, 2024.
Findings
The investigation concluded that the facility failed to provide adequate care and supervision to resident R1, who left the facility unattended despite having a documented diagnosis of dementia and a care plan addressing elopement risk. The resident was found unharmed approximately half a mile from the facility.
Complaint Details
The visit was complaint-related due to an incident where resident R1 eloped from the facility on May 15, 2024. The complaint was substantiated based on the findings of inadequate supervision and failure to implement safety measures.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Care of Persons with Dementia: Safety measures to address behaviors such as wandering were not met, evidenced by resident R1 leaving the facility unattended, posing an immediate health and safety risk. | Type A |
Report Facts
Capacity: 86
Plan of Correction Due Date: Jun 4, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mark Reyes | Administrator | Named in relation to the reported incident and during the exit interview |
| Jill Nakagawa | Licensing Program Analyst | Conducted the inspection and signed the report |
| Kimberley Mota | Licensing Program Manager | Supervisor and Licensing Program Manager overseeing the inspection |
Inspection Report
Original Licensing
Census: 10
Capacity: 86
Deficiencies: 0
Mar 8, 2024
Visit Reason
The inspection was a post licensing visit conducted unannounced to evaluate the facility following initial licensing.
Findings
The inspection found no deficiencies. Observations included unobstructed exits, complete first aid kits, adequate supplies, compliant fire extinguishers, proper medication storage, and regulatory compliance with water temperature and food supplies.
Report Facts
Residents in care: 10
Facility capacity: 86
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mark Reyes | Administrator | Met with Licensing Program Analysts during the inspection |
Inspection Report
Original Licensing
Capacity: 86
Deficiencies: 0
Jan 23, 2024
Visit Reason
The visit was a pre-licensing inspection conducted to evaluate the readiness of The Farmstead at Dixon for final approval and licensing.
Findings
The facility was found to be new, well-appointed, and prepared to serve independent living, assisted living, and memory care residents. No deficiencies were noted, and all areas including administration, food service, medication management, physical plant, and safety features were reviewed and found satisfactory.
Report Facts
Fire inspection approved capacity: 86
Hot water temperature deviation: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alana Reyes | Administrator | Met with Licensing Program Analyst during pre-licensing inspection |
| Jill Nakagawa | Licensing Program Analyst | Conducted the pre-licensing inspection |
Inspection Report
Original Licensing
Capacity: 86
Deficiencies: 0
Jan 16, 2024
Visit Reason
Initial licensing evaluation conducted via telephone call with the Community Care Licensing Division (CAB) to verify applicant and administrator understanding of Title 22 and facility operation requirements.
Findings
The applicant and administrator successfully completed Component II of the licensing process, demonstrating understanding of facility operation, admission policies, staffing, health conditions, general provisions, emergency preparedness, complaints and reporting, and pre-licensing readiness.
Report Facts
Capacity: 86
Census: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alana Reyes | Administrator | Participant in COMP II licensing evaluation |
| Jason Reyes | Owner | Participant in COMP II licensing evaluation |
| Shannon Betker | Analyst | CAB analyst conducting licensing evaluation |
| Jude De La Concepcion | Licensing Program Manager | Named in report header |
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