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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 570316115
Report Date: 07/09/2026
Date Signed: 07/09/2026 05:22:12 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
03/06/2026 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20260306093501
FACILITY NAME:CALIFORNIAN, THEFACILITY NUMBER:
570316115
ADMINISTRATOR:VALADEZ, FERNANDOFACILITY TYPE:
740
ADDRESS:1224 COTTONWOOD STREETTELEPHONE:
(530) 666-2433
CITY:WOODLANDSTATE: CAZIP CODE:
95695
CAPACITY:130CENSUS: 66DATE:
07/09/2026
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Fernando Valadez, AdministratorTIME COMPLETED:
05:20 PM
ALLEGATION(S):
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Licensee does not ensure facility's call pendants are operable
Staff do not respond to residents' calls for help timely
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Nakagawa arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations. LPA met with Administrator Fernando Valadez to discuss.

The complaint alleges that Licensee does not ensure facility's call pendants are operable and Staff do not respond to residents' calls for help timely. The complainant states that resident R1 fell while getting out of bed on 3/1/2026, and R1’s pendant was not working. It is not known how long R1 laid on the floor before staff found R1. Complainant states that the pendant was tested and found non-functioning and was then replaced by staff.

(Continued on 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2026
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-20260306093501
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: 07/09/2026
NARRATIVE
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(Continued from 9099)

On 03/10/2026, LPA inspected R1’s room and found the call pendant resident carries and the call alarm on the living room wall to be non-functioning. The call alarm in the bathroom was functioning at the time of visit. Based on the failure of the pendant and the call alarm in the living room the allegation that Licensee does not ensure facility's call pendants are operable, Staff do not respond to resident’s calls for help timely is substantiated. (Deficiencies cited)

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with Administrator and a copy of this report was given.

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

DATE: 07/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2026
LIC9099 (FAS) - (06/04)
Page: 2 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
03/06/2026 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20260306093501

FACILITY NAME:CALIFORNIAN, THEFACILITY NUMBER:
570316115
ADMINISTRATOR:VALADEZ, FERNANDOFACILITY TYPE:
740
ADDRESS:1224 COTTONWOOD STREETTELEPHONE:
(530) 666-2433
CITY:WOODLANDSTATE: CAZIP CODE:
95695
CAPACITY:130CENSUS: 66DATE:
07/09/2026
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Fernando Valadez, AdministratorTIME COMPLETED:
05:20 PM
ALLEGATION(S):
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Staff did not safeguard a resident's personal belongings
Staff left resident soiled in urine
INVESTIGATION FINDINGS:
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On 07/09/2026, Licensing Program Analyst (LPA) Nakagawa arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations. LPA met with Administrator Fernando Valadez to discuss.
The complaint alleges that Staff did not safeguard a resident's personal belongings. The complainant states R1 got hearing aid/aids on 10/17/2024; both were lost 10/22-25/2024, and 11/30/2024 the left hearing aid was lost and never found. Complainant stated new hearing aids were received 02/13/2025; on 01/11/2026, they were both lost and never recovered. LPA reviewed the inventory list of 02/24/2024, which was blank.

(Continued on 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 21-AS-20260306093501
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: 07/09/2026
NARRATIVE
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(Continued from 9099-A)

The inventory list of 02/26/2026 lists a Pocket-Talker hearing device, which
R1 currently has in their possession. R1’s Physician’s Report (dated 9/8/25) and Resident Appraisal (dated 02/16/24) state that R1 wears hearing aids. The service plan (dated 2/12/26) states that R1 is deaf or severely hearing impaired, needs adaptive equipment and frequent monitoring, but does not specify the use of hearing aids or their care. Based on the review of R1’s inventory and care plan the allegation that Staff did not safeguard a resident's personal belongings is unsubstantiated.

The complaint alleges that Staff left resident soiled in urine. The complainant stated that on 11/24/2025 R1 was found on the sofa with a wet brief. LPA reviewed care notes and interviewed staff. 3 of 3 staff stated that R1 received checks every 2 hours. Based on interviews with staff and care notes the allegation that Staff left resident soiled in urine 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.

Report reviewed with Administrator.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20260306093501
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: 07/09/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/09/2026
Section Cited
CCR
87303(i)(1)(B)
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87303 Maintenance and Operation (i)Facilities shall have signal systems which shall meet the following criteria:(1)All facilities licensed... all residential facilities having separate floors or buildings shal(B)Transmit a visual and/or auditory signal to a central staffed location or produce... to summon staff. This requirement was not met as evidenced by:
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Licensee to ensure call signal system is working correctly by submitting proof of a system test by July 13, 2026.
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Based on the failed testing of call bell and pendant on 3/10/2026 of R1 the licensee did not ensure the facility’s call pendants were operational; therefore facility was unable to perform timely response, including providing timely continence care. 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: 07/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5