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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 570316115
Report Date: 04/29/2026
Date Signed: 04/29/2026 12:39:08 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
11/18/2025 and conducted by Evaluator Jill Nakagawa
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20251118151726
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: 67DATE:
04/29/2026
ANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Fernando Valadez and Kathy Neeser, AdministratorsTIME COMPLETED:
12:40 PM
ALLEGATION(S):
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Staff did not medically intervene/perform basic first aid for resident resulting in resident's death.

INVESTIGATION FINDINGS:
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On April 29, 2026, Licensing Program Analyst (LPA) Nakagawa conducted an in-office meeting for the purpose of delivering complaint findings. LPA met with Administrator, Fernando Valadez. During the investigation, the Department reviewed records, conducted interviews with staff, outside parties, and made observations.

On 11/11/2025, Resident (R1) passed away with the immediate cause of death was choking with onset to minutes. Yolo County Coroner’s Office Deputy Coroner reported R1 choked while eating a hamburger and facility staff failed to intervene because R1 had a Do Not Resuscitate (DNR) on file. Emergency Medical Service (EMS) records documents that facility staff told paramedics that facility staff are not allowed to do any first aid, abdominal thrusts, or CPR.
(Continued on 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2026
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 4
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
11/18/2025 and conducted by Evaluator Jill Nakagawa
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20251118151726

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: 70DATE:
04/29/2026
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Fernando Valadez, AdministratorTIME COMPLETED:
12:40 PM
ALLEGATION(S):
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Staff are not properly trained.
INVESTIGATION FINDINGS:
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On April 29, 2026, Licensing Program Analyst (LPA) Nakagawa, Licensing Program Managers (LPMs) Kimberley Mota and Bethany Moellers, conducted an in-office meeting for the purpose of delivering complaint findings. LPA met with Administrators, Fernando Valadez and Kathy Neeser. During the investigation, the Department reviewed records, conducted interviews with staff, outside parties, and made observations.
The complaint alleges that staff are not properly trained. LPA reviewed training records and found that staff involved in the incident, S1 and S2, had received certification of basic first aid/CPR as per regulation. Based on LPA's review of training records the alllegation that staff are not properly trained is UNSUBSTANTIATED. Although the allegation may have occurred there is not a preponderance of evidence.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2026
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 4
Control Number 21-AS-20251118151726
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: 04/29/2026
NARRATIVE
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(Continued from 9099...)
R1’s Assessment and Service Plan dated 10/10/2025, noted they had eating difficulties, had prior incidents of choking, and required supervision during meals. On the day of the incident, staff were not supervising R1 as R1 was supervised by family. Family called for help and staff (S1) responded to assist. S1 reported R1 was coughing but did not perform the Heimlich maneuver and sought emergency medical services. 911 recording was obtained and it supports S1 failed to call 911 immediately for an emergency situation and called hospice first. Further, S1 reported to the 911 dispatcher that R1 was choking and is currently having shortness of breath, can’t breathe, and their lips were turning purple. There was no mention of R1 coughing. There were no staff providing medical care to R1 while S1 was on phone with the dispatcher. Dispatcher instructed S1 to place R1 flat on their back in order to perform CPR. S1 stated, “we can’t perform CPR.” Based on the evidence, there is sufficient information to corroborate that staff failed to provide basic first-aid.

Based on the department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 1, is being cited on the attached LIC 9099D. Appeal rights given.
An immediate civil penalty is being assessed today in the amount of $500 for a violation that resulted in the death of a resident in care.

The licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f)
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 21-AS-20251118151726
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: 04/29/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/29/2026
Section Cited
HSC
1569.269(a)(6)
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1569.269(a)(6)Enumerated rights:severability(a)Residents of residential care facilities...following rights:(6)To care, supervision....and competency to meet their needs...This requirement is not met as evidenced by:
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Licensee will ensure that all staff are trained on basic 1st aid vs. CPR per regulation and the needs and services of residents, including the special needs of residents with swallowing issues and other dietary needs. A plan will be submitted for this training by 4/30/2026 to LPA.
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Based on the Dept./Coroners investigation the...Licensee failed to ensure R1 care, supervision and services that meet their ind. needs and are delivered by staff.....which resulted in R1 death which poses an immediate health and safety risk to 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: 04/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 4