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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 570316115
Report Date: 08/15/2023
Date Signed: 08/15/2023 01:55:57 PM

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
07/21/2023 and conducted by Evaluator Farhaan Sarangi
COMPLAINT CONTROL NUMBER: 21-AS-20230721124842
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: 88DATE:
08/15/2023
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Med Tech, Meri Tibbs
Administrator, Kathy Neesen		TIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff do not ensure resident records are properly maintained
Staff do not ensure residents receive bathing assistance
Residents are left in soiled clothing for extended periods of time
Staff do not ensure residents are provided meal assistance
Staff lock residents in their rooms
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Californian, The for the purpose of continuing on a complaint investigation inspection and delivering complaint findings. LPA was greeted at the door by Med Tech, Meri Tibbs, and was granted access into the facility. Administrator arrived 30 minutes later.

During the course of the investigation, LPA interviewed staff and residents in care. In addition, LPA toured the facility on August 15, 2023 and reviewed a sample population of resident records.

Complaint alleges that Staff do not ensure resident records are properly maintained. Based on interviews that were conducted, LPA could not corroborate the allegation. On August 15, 2023, LPA observed resident records from an electronic database that contained records of ADLS for residents in placement. Furthermore, additional documents were reviewed and were properly maintained at the facility and in accordance with Title 22 regulations. (Report continued on LIC 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023
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-20230721124842
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: 08/15/2023
NARRATIVE
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Complaint alleges that Staff do not ensure residents receive bathing assistance. Based on interviews that were conducted, LPA received inconsistent statements as it relates to the allegation. Furthermore, during a tour of the facility on August 15, 2023, LPA observed a staff member inside the bathroom, and assisting a resident with a shower.

Complaint alleges that Residents are left in soiled clothing for extended periods of time. During a tour of the facility on August 15, 2023, LPA observed a staff member assisting a resident with soiled clothing. In addition, based on interviews that were conducted, LPA learned of no concerns regarding the care of residents in placement.

Complaint alleges that Staff do not ensure residents are provided meal assistance. Based on interviews that were conducted, LPA could not prove or disprove that the residents are not provided meal assistance. In addition, residents interviewed did not present concerns regarding meal assistance.

Complaint alleges Staff lock residents in their rooms. On August 15, 2023, LPA was able to interview a sample population of residents in their respective rooms. LPA also observed room doors being unlocked and accessible to residents, visitors and staff. Furthermore, during interviewing with residents and staff, LPA learned of no concerns nor could this allegation be corroborated.

A finding that the complaint allegations of Staff do not ensure resident records are properly maintained, Staff do not ensure residents receive bathing assistance, Residents are left in soiled clothing for extended periods of time, Staff do not ensure residents are provided meal assistance, Staff lock residents in their rooms are unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted and a copy of this was report was signed and given to the Administrator.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023
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
07/21/2023 and conducted by Evaluator Farhaan Sarangi
COMPLAINT CONTROL NUMBER: 21-AS-20230721124842

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: 88DATE:
08/15/2023
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Med Tech, Meri Tibbs
Administrator, Kathy Neesen		TIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Licensee does not ensure staff receive on the job training
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Californian, The for the purpose of continuing on a complaint investigation inspection and delivering complaint findings. LPA was greeted at the door by Med Tech, Meri Tibbs, and was granted access into the facility. Administrator arrived 30 minutes later.

During the course of the investigation, LPA interviewed staff and residents in care. In addition, reviewed a sample population of resident records and staff records.

Complaint alleges Licensee does not ensure staff receive on the job training. During the complaint investigation inspection dated for August 15, 2023, LPA reviewed the staff training for a sample population of staff, and learned via observation that a staff member did not have the annual training for the year of 2022 and 2023 (See LIC 9099D). Administrator disclosed to the LPA that the staff member did not have the annual training as outlined in Title 22 regulation. (Report continued on LIC 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023
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-20230721124842
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: 08/15/2023
NARRATIVE
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LPA educated the Administrator on the importance of ensuring that staff members are trained annually as outlined in Title 22 Regulations.

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 with the Administrator and appeal rights were provided.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20230721124842
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: 08/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/23/2023
Section Cited
CCR
87707(a)(2)
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87707(a)(2) Training Requirements If Advertising Dementia Special Care, Programming And/Or Environments:

(a) Licensees who advertise, promote, or otherwise hold themselves out as providing special care, programming, and/or environments for residents with dementia or related disorders shall ensure that all direct care staff, described in Section 87706(a)(1), who provide care to residents with dementia, meet the following training requirements:
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Plan of Correction shall include a written statement on how future compliance will be met. In addition, Administrator to ensure that ALL staff are trained in the performance of their respective duties.
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(2) Direct care staff shall complete at least eight hours of in-service training on the subject of serving residents with dementia within 12 months of working in the facility and in each succeeding 12-month period. Direct care staff hired as of July 3, 2004 shall complete the eight hours of in-service training within 12 months of that date and in each succeeding 12-month period.

This requirement was not met as evidenced by:

Based on observation of the training hours for staff members, LPA identified one staff member not having the necessary hours of training as outlined in Title 22 regulation. Staff member has not been trained annually since 2021 which presents a potential health, safety and personal rights risk to the residents in care.
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Licensee/Administrator to submit an LIC 9098.

POC due date by August 23, 2023.
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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: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5