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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 570316115
Report Date: 09/04/2024
Date Signed: 09/04/2024 02:44:25 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
05/23/2024 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20240523134233
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: 87DATE:
09/04/2024
UNANNOUNCEDTIME BEGAN:
11:18 AM
MET WITH:Kathy Neeser, Co- Administrator TIME COMPLETED:
02:43 PM
ALLEGATION(S):
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Staff do not ensure that resident is provided assistance.
Staff left residents in soiled clothing.
Staff did not provide adequate food service to resident in care.
Staff do not administer residents' medications as prescribed.

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Nakagawa met with Administrator Kathy Neeser for the purpose of delivering findings on the above captioned allegations. This investigation included interviews with witnesses: staff and other parties, as well as records and document reviews, photos and LPA observations. The following determinations were made: On August 7, 2024 LPA made an unannounced visit to the facility and inspected the Memory Care unit and found 33 residents, 2 care staff. There was one med tech. who came and went but did not provide care, only medication management, and one housekeeper. LPA found many residents sitting in the hallway and several residents in bed requesting care. LPA went into a resident’s room who requested help with consumption of a protein drink. LPA rang the bell for assistance without any response after 15 minutes. LPA notified the Administrator who found that the call bells were inoperable. LPA requested call bell records to verify response times but records unavailable due to a malfunction in the software program. Based on the time the LPA waited for someone to come and help the resident, the lack of a working call bell system and the staff scheduling for the unit the preponderance of evidence standard has been met therefore the Dept. finds the allegations that staff do not ensure that resident is provided assistance and staff did not provide adequate food service to resident in care is SUBSTANTIATED.

Continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024
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 4
Control Number 21-AS-20240523134233
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: 09/04/2024
NARRATIVE
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In addition, the complaint alleges that staff left residents in soiled clothing. LPA reviewed photos of R1 in only a diaper, which R1 was pulling apart. Based upon photos, records reviewed and statements taken from witnesses, the preponderance of evidence standard has been met. Therefore, the allegation that staff left residents in soiled clothing is SUBSTANTIATED.

The complaint also alleges that staff do not administer resident's medications as prescribed. LPA's review of resident R1's MAR lacks documentation and shows that medications were not given as ordered by the Physician. Based on LPA interviews, and review of information obtained, the investigation has revealed that the allegation staff failed to administer resident's medication as prescribed is SUBSTANTIATED.

The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.

SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 21-AS-20240523134233
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: 09/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/04/2024
Section Cited
CCR
87555(a)
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87555 General Food Service Requirements (a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner. Based upon LPA's observations Licensee did not provide adequate assistance in serving food in a safe and healthful manner.

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Licensee to ensure that staff understand the importance of meeting the dietary needs of the residents by conducting a training on the Regulation 87555.
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This requirement is not evidenced by : Based on LPA observation of resident unable to receive assistance.This is an immediate risk to the Health, Safety and Rights of residents in care.
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Administrator to provide a date of training by 9/5//2024. Proof of training (sign-in sheet) and training materialsto be submitted to LPA by 09/12/2024.
Type A
09/04/2024
Section Cited
CCR
87411(a)
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87411(a) Personnel Requirements – General- (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by:
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Licensee to ensure staff are sufficient in numbers to meet the needs of residents. Licensee agrees to submit updated staffing schedule, showing 24-hour coverage to meet the needs of residents. Updated staffing schedule to be submitted to CCL by POC date of COB 09/05/2024..
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Based on LPA observation, interview and record review residents were not able to receive care in a timely manner. This is an immediate risk to the Health, Safety and Rights 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.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 21-AS-20240523134233
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: 09/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/04/2024
Section Cited
CCR
87465(c)(2)
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Incidental Medical and Dental Care (c) (2)- Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by LPA's review of records and interviews.
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Administrator to ensure that the facility staff that handle medication assistance to residents in care are in-serviced on Medication Policies of the facility in regards to medication orders and documentation of medication assistance. Submit plan of training by 9/5/2024.
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The LPA reviewed records, and conducted interviews with staff. The investigation revealed that R1 had a medicated patch ordered to be applied in AM and removed in PM. MAR shows patch applied but documentation for removal was missing several entries. This is a potential health and safety risk to resident in care.
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Please submit proof of training (sign-in sheet) and copy of training materials by 9/15/2024.
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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.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4