<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 570316115
Report Date: 09/04/2024
Date Signed: 09/04/2024 11:47:00 AM

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
05/14/2024 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20240514153351
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:
09:40 AM
MET WITH:Kathy Neeser, Co-AdministratorTIME COMPLETED:
11:18 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not comply with Infection control requirements
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Nakagawa arrived at the facility unannounced on 09/04/2024 and conducted an investigation into the allegation “Staff did not comply with Infection control requirements”. The complainant states that the facility administration was negligent by not responding to staff and residents testing positive to Covid-19 and taking precautions in a timely manner which led to an outbreak which could have been avoided.

LPA Nakagawa was first informed by phone by Administrator of (1) positive case on 5/10/2024. A second case was documented on 5/11/2024. It was not until 5/13/2024 that additional cases of staff were confirmed, raising the number of positive cases to Outbreak status.


Continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
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 2
Control Number 21-AS-20240514153351
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
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from 9099

At that point the facility tested residents and a Line List of testing was submitted to CCL (Community Care Licensing) and Yolo County Public Health.

The CCL Regional Office and Yolo County Public Health received notification of an outbreak on 5/14/2024, which is within the required reporting guidelines.

As the complaint was filed anonymously, the Department was unable to ascertain from the reporting party the identities of any staff or residents with potential symptoms ignored by the Administrator prior to 5/10/2024 which may have hindered the isolation and containment of the virus in the facility.

The Department found that Staff did comply with Infection control requirements. Administrator did enact their Infection Control Plan: contacting the Dept. of Public Health, using PPE, isolating positive residents, closing the dining room, discontinuing other activities. 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 that Staff did not comply with Infection control requirements is unsubstantiated.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
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 2