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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 570316115
Report Date: 06/23/2021
Date Signed: 06/23/2021 02:04:55 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/22/2021 and conducted by Evaluator Farhaan Sarangi
COMPLAINT CONTROL NUMBER: 21-AS-20210622135344
FACILITY NAME:CALIFORNIAN, THEFACILITY NUMBER:
570316115
ADMINISTRATOR:KATHY B. NEESERFACILITY TYPE:
740
ADDRESS:1224 COTTONWOOD STREETTELEPHONE:
(530) 666-2433
CITY:WOODLANDSTATE: CAZIP CODE:
95695
CAPACITY:130CENSUS: 81DATE:
06/23/2021
UNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Administrator, Kathy B. NeeserTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility confined residents to thier rooms
Facility staff is not providing adequate activities for the residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived at The Californian unannounced to open a complaint. LPA Sarangi met with Administrator, Kathy B. Neeser and was granted access into the facility. LPA conducted the visit outside due to COVID-19 precautions.

During the opening of this complaint, LPA interviewed the Administrator and requested the following documents:

-Staff Roster
-Resident Roster
-Mitigation Plan
-Activities list
-Email to the Responsibile Parties
-Facility dining menu
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021
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 2
Control Number 21-AS-20210622135344
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: CALIFORNIAN, THE
FACILITY NUMBER: 570316115
VISIT DATE: 06/23/2021
NARRATIVE
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During facility surveillance testing, facility was notified of two positive cases on June 18, 2021. Facility is following there Approved Mitigation Plan regarding COVID-19. In addition, facility is also in compliance with PIN 21-17. Facility is following quarantining guidelines.

PIN 21-17:

B. COMMUNAL DINING, GROUP ACTIVITIES, AND NON-ESSENTIAL SERVICES (Page 13)

"If you are NOT UNDER QUARANTINE then you may eat in the same room and participate in group activities with other residents."

C. COMMUNAL DINING, GROUP ACTIVITIES, AND NON-ESSENTIAL SERVICES (Page 8 and 9)

Regardless of their vaccination status, any resident or staff who was exposed to COVID-19 must quarantine to a single room.

D. RESIDENTS RETURNING FROM OUTINGS (Page 9)

This states that anyone who has been in close contact with someone who tested positive should quarantine.



Based on the interview that was conducted and the documents reviewed at the facility, the allegations of, Facility confining residents to their rooms and Facility staff is not providing adequate activities for the residents is Unfounded A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2