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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 570316115
Report Date: 04/28/2021
Date Signed: 05/03/2021 05:46:40 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/18/2020 and conducted by Evaluator Katrina Walters
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20200918114156
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: DATE:
04/28/2021
UNANNOUNCEDTIME BEGAN:
02:27 PM
MET WITH:Kathy NeeserTIME COMPLETED:
06:30 PM
ALLEGATION(S):
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Food Service is inadaquate.
Staff are not calling 911 in a timely manner.
Management is asking the staff to falsify medical documention to the paramedics.
Staff are not trained to assist residents with medications.
INVESTIGATION FINDINGS:
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On 4/28/2021 Licensing Program Analyst (LPA) Katrina Walters met with Administrator, Kathy Neeser via Televisit to deliver findings regarding the above complaint allegations. This visit was completed via tele-visit due to Covid-19 precautions.

The complainant alleges: Management is asking the staff to falsify medical documentation to the paramedics; Food Service is inadequate and Staff are not calling 911 in a timely manner. During the course of this investigation LPA interviewed staff, and various outside parties, conducted a virtual tours of the facility on 9/23/2020 and 3/22/2021, reviewed various documents such as police records, facility call logs, incident reports, daily staffing assignments, timesheets, training records and resident records.

Continued on 9099 C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2021
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 7
Control Number 21-AS-20200918114156
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: CALIFORNIAN, THE
FACILITY NUMBER: 570316115
VISIT DATE: 04/28/2021
NARRATIVE
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Continued from 9099.

Allegation- Food Service is inadequate- Based on interviews, review of menu, and LPA observations during virtual tour of the facility, LPA learned the following: LPA observed that the facility has food carts to keep the keep food warm while delivering residents food. LPA interviewed staff and residents who confirmed that food seems to be adequate. LPA observed the facility menu and food was of quality and in the quantity necessary to meet the needs of the residents, as required by regulation. Therefore this allegation is UNSUBSTANTIATED.

Allegations- Staff are not calling 911 in a timely manner and Management is asking the staff to falsify medical documentation to the paramedics- LPA interviewed staff and Administrator, reviewed documents and police service calls to this facility and was unable to verify these incidents. The complainant was unable to provide LPA with any witnesses to these events. Therefore this allegation is UNSUBSTANTIATED.

Allegation- Staff are not trained to assist residents with medication- Based on interviews, a review of staff training records and five resident’s MAR’s LPA learned that all staff assisting residents were provided with medication training as required per title 22 regulations, therefore the allegation is UNSUBSTANTIATED.

A finding for the above allegations are unsubstantiated meaning that although the allegation may have happened there is not a preponderance of evidence to prove that the allegation occurred. We have therefore dismissed the complaint. Exit interview conducted with Administrator Kathy Neeser. LPA sent copy report to Kathy Neeser for signature. No deficiencies cited.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/18/2020 and conducted by Evaluator Katrina Walters
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20200918114156

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: DATE:
04/28/2021
UNANNOUNCEDTIME BEGAN:
02:27 PM
MET WITH:Kathy NeeserTIME COMPLETED:
06:30 PM
ALLEGATION(S):
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Staff are not assisting residents with incontinence.
Staff are not meeting the needs of the residents.
Staff are not answering resident calls in a timely manner.
Staff are not assisting with administration of medication in a timely manner.
INVESTIGATION FINDINGS:
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On 4/28/2021 Licensing Program Analyst (LPA) Katrina Walters met with Administrator, Kathy Neeser via Televisit to deliver findings regarding the above complaint allegations. This visit was completed via tele-visit due to Covid-19 precautions.

During the course of this investigation LPA interviewed staff, and various outside parties, conducted virtual tours of the facility on 9/23/2020 and 3/22/2021, reviewed various documents such as facility call logs, incident reports, daily staffing assignments, call button logs, timesheets, training records and resident records.

Continued on 9099 C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2021
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 7
Control Number 21-AS-20200918114156
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: CALIFORNIAN, THE
FACILITY NUMBER: 570316115
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/29/2021
Section Cited
CCR
87465(a)(5)
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87465(a) A plan for incidental medical ..(5) The licensee shall assist residents with self-administered medications as needed..*Based upon interviews and records reviewed this requirement has not been met as
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Administrator will provide proof of PRN training to CCL attention LPA Walters by 4/29/21.
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evidenced by: S1 did not provide resident with PRN in a timely manner. This posed an immediate 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: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 21-AS-20200918114156
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: CALIFORNIAN, THE
FACILITY NUMBER: 570316115
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/29/2021
Section Cited
CCR
87625(b)(3)
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87625 Managed Incontinence (b)(3)(b) In addition ..(3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. *Based upon records reviewed and interviews
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Per Administrator they will conduct an in-service for incontinance, increase audtis, implement an award system for staff. Administrator to send proof of their plans to LPA Walters by email 4/29/21.
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this requirement has not been met as evidenced by: Facility staff did not provided incontinence care to residents. This posed an immediate risk to the health and safety of residents in care.
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Type B
05/03/2021
Section Cited
HSC
1569.269
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1569.269 Enumerated rights; severability(6) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency
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Administrator will provide proof that staff are cross trained to provide care in additional area's of the facility. In addition, to CCL by 5/3/21.
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to meet their needs. *Based upon records reviewed, This requirement has not been met as evidenced by: Staff were unable to provide care to residents in care on 88 occasions. This posed a potential 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: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 21-AS-20200918114156
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: CALIFORNIAN, THE
FACILITY NUMBER: 570316115
VISIT DATE: 04/28/2021
NARRATIVE
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Continued from 9099
Allegation- Staff are not answering resident calls in a timely manner. Based on interviews with Staff and records reviewed, LPA learned the following: LPA conducted interviews with staff. 2 of 6 staff confirmed that they were unable to answer resident's calls in a timely manner at the time of complaint. LPA reviewed facility call log records (8/1 -8/31/2020) Call log records indicate that on 88 occasions, facility staff took an excess of 20 minutes or longer to respond to residents’ calls. Per Administrator the expectation is that staff respond within 7-10 minutes of the resident’s call. Therefore, this allegation is SUBSTANTIATED.

Allegations-Staff are not meeting the needs of the residents and Staff are not assisting residents with incontinence. Based on interviews from staff and a review of five
incontinent resident’s Physician Report’s (602), Staff Services Checkoff list and review of resident call logs the LPA learned the following: Call logs indicate that on 8/28/20 R2 waited in the bathroom for 16:18 minutes for staff to respond after they pulling the call cord. Then again on 8/17/2-20 R2 waited 55:45 minutes for staff to respond to call after pulling the call cord while in the bathroom. R2’s Physician’s Report confirms they’re in need of incontinence care. Therefore, the allegations are SUBSTANTIATED.

Allegation- Staff are not assisting with administration of medication in a timely manner. Based on Interviews, Woodland Police Department Records, Resident's daily medication chart, and call button logs, LPA learned the following: It was alleged that an altercation occurred involving Staff (S1) and Registry Staff (RS1) on 9/15/2020. During confidential interviews, LPA learned that RS1 call for a PRN medication for resident (R4) using the facility walkie. S1 reported that they didn't hear multiple calls for medication for RS1, however multiple staff report hearing RS1 call for a medication technician to provide medication. Staff were unable to locate a medication technician. Based on review of call logs, R4 called for assistance to their bedroom, and carestaff responded 35 minutes later. The Medication logs reveal R4 was given their PRN medication, 1 hour after calling for assistance. Therefore the allegation is SUBSTANTIATED.

Continued on 9099C
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 21-AS-20200918114156
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: CALIFORNIAN, THE
FACILITY NUMBER: 570316115
VISIT DATE: 04/28/2021
NARRATIVE
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Continued from 9099C

Based on the above information provided the preponderance of evidence standard has been met, therefore the above allegations are Substantiated (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and or Health and Safety Code. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted and appeal of rights provided. LPA sent copy report to Kathy Neeser for signature.

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2021
LIC9099 (FAS) - (06/04)
Page: 7 of 7