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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 570316115
Report Date: 08/28/2023
Date Signed: 08/28/2023 02:44:20 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
07/18/2023 and conducted by Evaluator Farhaan Sarangi
COMPLAINT CONTROL NUMBER: 21-AS-20230718123430
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: 91DATE:
08/28/2023
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Administrator, Kathy NeeserTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility is allowing unauthorized staff to provide care and supervision to residents.
Medications are accessible to residents in care.
Facility is not adequately staffed to meet the needs of residents in care.
Facility is not meeting resident's oral hygiene needs.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Farhaan Sarangi arrived at Californian, The unannounced for the purpose of delivering complaint findings. LPA met with Executive Director, Kathy Neeser.

During the course of the investigation, LPA interviewed staff and residents in care. LPA reviewed a sample of resident records and reviewed facility records. LPA obtained an outside agency report which was reviewed. In addition, LPA toured the facility on August 15, 2023.

Complaint alleges that facility is allowing unauthorized staff to provide care and supervision to residents. Based on an observation of faciltiy records which were conducted on August 4, 2023, the alleged staff member was observed on the Guardian List and background clearance list. The alleged staff member was allowed to provide care and supervision to residents in placement.

Complaint alleges Medications are accessible to residents in care. (Report continued on LIC 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023
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-20230718123430
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: 08/28/2023
NARRATIVE
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Based on interviews that were conducted, LPA could not prove or disprove the allegation. In addition, LPA learned of no concerns during resident interviews. On August 15, 2023, LPA toured the facility and found that the Medication Room was locked and secured.

Complaint alleges that Facility is not adequately staffed to meet the needs of residents in care. During the tour on August 15, 2023, LPA observed sufficient staff that met the resident needs. In addition, LPA observed a resident being attended to. LPA reviewed the employee roster which was found to be appropriate. However, during the review of the Call Bell Logs for the dates of June 15, 2023 through July 3, 2023, LPA observed that residents had to wait for a prolonged periods of time in excess of 30+ minutes to receive assistance (See LIC 809-Case Management-Deficiencies dated for August 28, 2023). LPA educated the Administrator on the importance of answering Call Bells in a timely manner.

Complaint alleges Facility is not meeting resident's oral hygiene needs. Based on interviews that were conducted, LPA could not prove or disprove the allegation. Furthermore, during interviewing, LPA received inconsistent statements regarding the allegation.

A finding that the complaint allegations of Facility is allowing unauthorized staff to provide care and supervision to residents, Medications are accessible to residents in care, Facility is not adequately staffed to meet the needs of residents in care and Facility is not meeting resident's oral hygiene needs 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: 08/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023
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
07/18/2023 and conducted by Evaluator Farhaan Sarangi
COMPLAINT CONTROL NUMBER: 21-AS-20230718123430

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: 91DATE:
08/28/2023
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Administrator, Kathy NeeserTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Personal Rights
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Farhaan Sarangi arrived at Californian, The unannounced for the purpose of delivering complaint findings. LPA met with Executive Director, Kathy Neeser.

During the course of the investigation, LPA interviewed staff and residents in care. LPA reviewed a sample of resident records and reviewed facility records. LPA obtained an outside agency report which was reviewed.

Complaint alleges Personal Rights. Based on interviews that were conducted, LPA was made aware that the alleged staff member was rude to a resident in care. Furthermore, LPA learned of an incident that occurred on June 28, 2023 in which the alleged staff member was asked to leave the facility after a meeting with Human Resources (HR). LPA obtained an outside agency report which was reported that the alleged staff member would leave and then return back to yell and curse at employees in the presence of residents (See LIC 9099D). LPA educated the Administrator on the importance of ensuring that staff members are affording residents Personal Rights as outlined in Title 22 Regulations. (Report continued on LIC 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023
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-20230718123430
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: 08/28/2023
NARRATIVE
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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: 08/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20230718123430
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: 08/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/29/2023
Section Cited
CCR
87468.1(a)(2)
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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:
(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
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Plan of Correction shall include retraining ALL staff as it relates to Personal Rights and ensuring that residents are afforded Personal Rights. In addition, Administrator shall provide a written summary on how future compliance will be met and an LIC 9098-Self Certification
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This requirement was not met as evidenced by:

Based on interviews that were conducted, LPA was made aware that the alleged staff member was rude to a resident in care. Furthermore, LPA learned of an incident that occurred on June 28, 2023 in which the alleged staff member was asked to leave the facility after a meeting with Human Resources (HR). LPA obtained an outside agency report which was reported that the alleged staff member would leave and then return back to yell and curse at employees in the presence of residents which presents an immediate health, safety and PERSONAL RIGHTS risk to the residents in care.
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Summary for future compliance-Plan of Correction due on August 29, 2023.

Training Plan of Correction due on September 11, 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: 08/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5