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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 570316115
Report Date: 07/24/2025
Date Signed: 08/07/2025 11:58:33 AM

Unsubstantiated


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
03/12/2025 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20250312135607
FACILITY NAME:CALIFORNIAN, THEFACILITY NUMBER:
570316115
ADMINISTRATOR:VALADEZ, FERNANDOFACILITY TYPE:
740
ADDRESS:1224 COTTONWOOD STREETTELEPHONE:
(530) 666-2433
CITY:WOODLANDSTATE: ZIP CODE:
95695
CAPACITY:130CENSUS: 78DATE:
07/24/2025
UNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Fernando Valadez, AdministratorTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Personal rights
INVESTIGATION FINDINGS:
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This is an amended version of a report signed on 07/24/2025.
Licensing Program Analyst Jill Nakagawa arrived unannounced to conduct investigation and deliver amended findings regarding the above allegation. LPA met with Administrator Fernando Valadez.

The complaint alleges that Resident (R1’s) personal rights were violated. The complainant states medications that should have been ordered through the VA (Veterans Administration) at no cost to R1 were ordered through another pharmacy which incurred out of pocket costs.
Continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025
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 5
Control Number 21-AS-20250312135607
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: 07/24/2025
NARRATIVE
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Continued from 9099...

This is an amended report from 07/24/2025.

LPA discovered through interviews that due to a supply issue the Licensee was unable to obtain medications through the VA and used another pharmacy which was authorized by R1's responsible party signing a Pharmacy Agreement on 06/22/2023. LPA found the Licensee paid the responsible party $961.63 for the costs incurred as a courtesy. Based on the signed Pharmacy Agreement the allegation that resident’s personal rights were violated is unsubstantiated.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20250312135607
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: 07/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/24/2025
Section Cited
CCR
87468.1(a)(16)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(16)To receive or reject medical care or other services.
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Administrator to submit a written plan to CCL on how they will ensure that billing procedures regarding medications will be followed by 07/29/2025.

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 This requirement was not met as evidenced by: Based on financial statement for R1, the Licensee did not comply with R1’s requested medical services and R1 incurring uncovered medical expenses which poses a potential risk to the health, safety or personal rights risk to residents.
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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: 07/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025
LIC9099 (FAS) - (06/04)
Page: 3 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
03/12/2025 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20250312135607

FACILITY NAME:CALIFORNIAN, THEFACILITY NUMBER:
570316115
ADMINISTRATOR:VALADEZ, FERNANDOFACILITY TYPE:
740
ADDRESS:1224 COTTONWOOD STREETTELEPHONE:
(530) 666-2433
CITY:WOODLANDSTATE: ZIP CODE:
95695
CAPACITY:130CENSUS: 78DATE:
07/24/2025
UNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Fernando Valadez, AdministratorTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Licensee did not follow physician's orders
INVESTIGATION FINDINGS:
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On 07/24/2025, Licensing Program Analyst Jill Nakagawa arrived unannounced to conduct further investigation and deliver findings regarding the above allegation. LPA met with Administrator Fernando Valadez.
***This is an amended report.

The complaint alleges that the Licensee did not follow physician’s orders. According to the complainant Resident (R1’s) physician had discontinued their medication as of June 27, 2024, but the facility had been continuing to dispense until February 2025. LPA Nakagawa reviewed the medical records for R1. An order issued by VA staff via electronic signature on June 27, 2024 at 12:25 pm indicates that the medication Mirtazapine be discontinued.
Continued on 9099-C.....

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

DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20250312135607
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: 07/24/2025
NARRATIVE
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Continued from 9099A

A review of the Electronic Medication Administration Record (EMAR) shows that it was updated by facility staff (S1) and verified by (S2) on the same day to reflect the change. Electronic Medication Administration Records (EMAR) indicate that the medication Mirtazapine was discontinued on June 27, 2024, by VA (Veterans Administration) staff. On September 7, 2024 (R1) received a new order re-starting Mirtazapine (same dosage) by their physician, not with the VA. EMAR records show medication being administered the same day as order received. On December 27, 2024, R1 received a new order for Mirtazapine under a new physician’s order, which is indicated in the EMAR. In addition, the complainant stated that R1 received an additional flu vaccine after receiving one from a care provider. Facility was provided a standing order signed by a physician for a yearly flu vaccine. Staff (S3) stated that a call to responsible party approved the administration of the vaccine. R1 received the flu shot on November 25, 2024, at 10 AM based on the medical information they had. It was not until later, upon receiving a bill for the vaccine that it was discovered that R1 had already received a vaccine from their care team prior to the November 25, 2024 vaccine, however that information had not been given to the facility. Based on medical, pharmacy and medication administration records, the allegation that the Licensee did not follow physician’s orders is unsubstantiated. Although the allegation may have occurred there is not a preponderance of evidence therefore the allegation is unsubstantiated.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5