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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 570316115
Report Date: 10/24/2024
Date Signed: 10/24/2024 01:50:20 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
09/12/2024 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20240912175632
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: 89DATE:
10/24/2024
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Fernando Valadez, Co-AdministratorTIME COMPLETED:
01:50 PM
ALLEGATION(S):
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Facility is in disrepair
Staff did not respond to resident's call for assistance in a timely manner
Staff mismanaged resident's medication
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jill Nakagawa arrived at The Californian on 10/24/2024 to complete an investigation and deliver findings on the above allegations.
The complaint alleges that at the time Resident (R1) moved into the facility, the air-conditioning in R1’s apartment was not functioning. Portable air-conditioners were provided to R1. Outside temperatures ranged from 89 degrees to 105 degrees per Accuweather records. On September 3, 2024 a maintenance log shows the toilet seat was loose and shifting, and on September 7, 2024 the maintenance log shows that the service pull cord had to be switched due to R1 not being able to pull cord.

Continued on 9099-C...

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
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 5
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
09/12/2024 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20240912175632

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: DATE:
10/24/2024
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Fernando Valadez, Co-AdministratorTIME COMPLETED:
01:50 PM
ALLEGATION(S):
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Staff did not maintain a comfortable temperature for residents at all times
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to complete an investigation ragarding the above allegation and deliver findings.

The complaint alleges that staff did not maintain a comfortable temperature for residents at all times. LPA conducted interviews and reviewed records. It was learned that the A/C unit in R1’s room was in need of repairs and that the facility brought in portable air conditioning units in an attempt to regulate the temperature in the apartment. There is no record of the temperature in the apartment during this time. Therefore, the allegation that staff did not maintain a comfortable temperature for residents at all times is unsubstantiated. 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.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20240912175632
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: CALIFORNIAN, THE
FACILITY NUMBER: 570316115
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/24/2024
Section Cited
CCR
87303(a)
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87303(a)87303 Maintenance and Operation (a) The facility shall be clean, safe... in good repair at all times. Maintenance shall include provision of maintenance services... well-being of residents, employees and visitor. This was not met as evidenced by:
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Administrator has submitted written plan of action to ensure units are ready for resident move-ins to LPA on 10/24/2024.
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Based on maintenance records and interviews the facility did not ensure that facility was within regulation due to air conditioner toilet and pull cord needing repairs. This is a potential risk to the health and safety of residents in care.
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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: 10/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 21-AS-20240912175632
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: CALIFORNIAN, THE
FACILITY NUMBER: 570316115
VISIT DATE: 10/24/2024
NARRATIVE
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Continued from 9099....

Based on LPA’s review of records and interviews, the preponderance of evidence standard has been met, therefore the allegation that the facility was in disrepair is substantiated. California Code of Regulations, (Title 22, Division 6 & Chapter 8), are being cited on the attached LIC 9099D.”)

The complaint alleges that R1 attempted to make contact with staff by pulling the emergency cord in their apartment, but it was broken and reported to staff on September 7, 2024. R1 then used their emergency necklace and staff did not respond for over 30 minutes. LPA reviewed call bell records and found that call bell response times for R1 on September 7, 2024 were not answered in a timely manner, taking 20-40 minutes to be answered on three calls. Based on interviews conducted and records reviewed the preponderance of evidence standard has been met, therefore the allegation that staff did not respond to resident’s call for assistance in a timely manner is found to be Substantiated. California Code of Regulations, (Title 22, Division and Chapter #) are being cited on the attached 9099D.

The complaint alleges that staff attempted to administer medication to R1 that was not prescribed by R1’s physician. Staff acknowledged the medication error after R1 refused the medication. Based on interviews conducted the preponderance of evidence standard has been met, therefore the allegation that staff mismanaged resident’s medication is found to be Substantiated. California Code of Regulations, (Title 22, Division 6 and Chapter 8) are being cited on the attached 9099D.)
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20240912175632
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: CALIFORNIAN, THE
FACILITY NUMBER: 570316115
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/24/2024
Section Cited
CCR
87411(a)
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87411(a) Facility personnel shall at all times be sufficient in numbers & competent to provide the services necessary to meet resident needs…This requirement has not been met as evidence by:**
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Licensee failed to ensure staff responded appropriately to call bell system and meet resident care needs in a timely manner. Licensee shall conduct staff training on how call bells will be responded to and provide a 7 day alarm response log to Licensing by 10/25/24 along with training plan.
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Based on records review of alarm response system and interviewsAdministrator did not ensure that staff on duty responded in a timely manner to call system to assist residents in care. Some call bell response times for R1 were 20- 40 minutes, which poses an immediate risk to the health and safety of residents in care.
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Verification of training by POC due date 10/30/2024.
Type A
10/24/2024
Section Cited
CCR
87465(a)(5)
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Incidental Medical and Dental Care Services.(a) The licensee shall assist residents with self-administered medications when needed.
This requirement is not met as evdenced by:
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Administrator agrees to ensure staff have additional medication training on the 7 Rights of Medication Administration before passing medication.
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Based on interviews and record review, staff attempted to administer the wrong medication to the wrong resident, which is an immediate risk to the health and safety of residents in care.
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Administrator to submit plan of training by 10/26/2024 and proof of training of staff handling medications by 10/30/2024.
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: 10/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5