The Californian

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Jill Nakagawa arrived on 09/04/2026 for an unannounced inspection to follow up on substantiated complaint findings, Complaint # 21-AS-20251118151726 delivered on 04/29/2026. LPA Nakagawa met with Administrator Fernando Valadez and reviewed the report. On 04/29/2026, the Department concluded a complaint investigation regarding the following allegation: Staff did not medically intervene/perform basic first aid for resident resulting in resident's death. The licensee was cited for Health & Safety Code 1569.269(a)(6) Enumerated rights: severability. At the time of the office visit on 04/29/2026, an immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1569.49. The Department has concluded an analysis and has determined that an additional civil penalty is warranted for a violation that resulted in the death of Resident (R1) while under the care of this facility. This is evidenced by the licensee failing to provide basic first aid while R1 was choking resulting in R1’s death. (Continued on 809-C) Continued from 809) Today, 09/04/2026, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49(e) for a violation that the Department constitutes as serious bodily injury resulting in death in the amount of $15,000. However, since an immediate civil penalty of $500 was previously issued on 04/29/2026, the amount of the civil penalty issued today will be $14,500. Exit interview conducted. A copy of the report issued. Appeal rights provided. Fernando Valadez, Administrator and signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Sep 4, 2026

Allegation investigated: Staff are not addressing bed bugs at facility Staff do not provide residents with laundry service Staff do not answer residents' call buttons in a timely manner Facility smells malodorous Staff do not serve residents meals free from contamination

On 07/14/2026, Licensing Program Analyst (LPA) Nakagawa arrived unannounced to conclude an investigation regarding the above allegations and deliver findings. LPA met with Administrator Fernando Valadez to discuss. The complaint alleges Staff are not addressing bed bugs at the facility. The complainant states that since November 2025, the facility has had bed bugs but managers are not addressing the matter. LPA reviewed photos and text message from complainant which show the date of 02/15/2026. An incident report filed by Administrator self-reported the discovery of bed bugs in a resident’s room on the same date, 02/15/2026. (Continued on 9099-C) Unsubstantiated (Continued from 9099) Administrator reported that the resident was moved from the infested room and an exterminator called, who responded in less than 24 hours, treating the infestation in the room and began a multi-step mitigation treatment for the building to ensure the bug infestation was isolated and treated completely. A statement from exterminator for the initial treatment is dated 2/16/2026. Based on the review of the exterminator’s treatment plan and moving the resident the allegation that Staff are not addressing bed bugs at the facility is Unsubstantiated. 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 is unsubstantiated. The complaint alleges that Staff do not provide residents with laundry service and Facility is malodorous. The complainant stated that due to lack of staff, residents are not receiving laundry service, that the facility smells bad and that residents' rooms are not being cleaned. LPA reviewed staffing schedules and timesheets for the laundry/housekeeping team and found adequate staffing. In addition, the facility has large capacity washers and dryers to wash residents’ clothes and beddings on demand, so soiled bed linens and clothing are washed quickly, without soiled linens producing malodorous smells. LPA toured the facility on several occasions (04/30/26, 07/02/26, 7/9/26) and checked several rooms on the first floor, second floor, hospice unit and memory care unit and found rooms to be clean and well-maintained, with no foul-smelling odors from garbage, soiled incontinence products or soiled laundry therefore the allegations that Staff do not provide residents with laundry service and Facility is malodorous are unsubstantiated. 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 is unsubstantiated. The complaint alleges that Staff do not serve residents meals free from contamination. The complainant states that staff serves residents expired food. Complainant stated that months ago residents became sick with diarrhea and vomiting and complainant feels that the residents' illnesses were related to the expired foods. LPA reviewed records and found no reported outbreaks at the facility within the last year. LPA inspected the kitchen on (10/17/2025, 4/30/2026, 7/7/2026) and found the kitchen to be clean and sanitary. Food was stored as per regulation, with expiration dates visible. No foods were found to be expired. Dietary staff were observed to be using appropriate food-handling protocols. Based on LPA’s observations the allegation that Staff do not serve residents meals free from contamination is unsubstantiated. (Continued on 9099-C) (Continued from 9099-C) 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 is unsubstantiated. The complaint alleges that Staff do not answer residents' call buttons in a timely manner. This allegation was investigated under complaint #21-AS-20260306093501. Findings reviewed with Administrator. A copy of the report was left with Administrator.the state’s words, verbatim · CDSS document, Jul 14, 2026 · control 21-AS-20260428081200

Allegation investigated: Licensee does not ensure facility's call pendants are operable Staff do not respond to residents' calls for help timely

Licensing Program Analyst (LPA) Nakagawa arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations. LPA met with Administrator Fernando Valadez to discuss. The complaint alleges that Licensee does not ensure facility's call pendants are operable and Staff do not respond to residents' calls for help timely. The complainant states that resident R1 fell while getting out of bed on 3/1/2026, and R1’s pendant was not working. It is not known how long R1 laid on the floor before staff found R1. Complainant states that the pendant was tested and found non-functioning and was then replaced by staff. (Continued on 9099-C) Substantiated (Continued from 9099) On 03/10/2026, LPA inspected R1’s room and found the call pendant resident carries and the call alarm on the living room wall to be non-functioning. The call alarm in the bathroom was functioning at the time of visit. Based on the failure of the pendant and the call alarm in the living room the allegation that Licensee does not ensure facility's call pendants are operable, Staff do not respond to resident’s calls for help timely is substantiated. (Deficiencies cited) Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given. (Continued from 9099-A) The inventory list of 02/26/2026 lists a Pocket-Talker hearing device, which R1 currently has in their possession. R1’s Physician’s Report (dated 9/8/25) and Resident Appraisal (dated 02/16/24) state that R1 wears hearing aids. The service plan (dated 2/12/26) states that R1 is deaf or severely hearing impaired, needs adaptive equipment and frequent monitoring, but does not specify the use of hearing aids or their care. Based on the review of R1’s inventory and care plan the allegation that Staff did not safeguard a resident's personal belongings is unsubstantiated. The complaint alleges that Staff left resident soiled in urine. The complainant stated that on 11/24/2025 R1 was found on the sofa with a wet brief. LPA reviewed care notes and interviewed staff. 3 of 3 staff stated that R1 received checks every 2 hours. Based on interviews with staff and care notes the allegation that Staff left resident soiled in urine is unsubstantiated. 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 is unsubstantiated. Report reviewed with Administrator.the state’s words, verbatim · CDSS document, Jul 9, 2026 · control 21-AS-20260306093501

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(i)(1)(B) · Plan of correction due date: Jul 9, 2026

87303 Maintenance and Operation (i)Facilities shall have signal systems which shall meet the following criteria:(1)All facilities licensed... all residential facilities having separate floors or buildings shal(B)Transmit a visual and/or auditory signal to a central staffed location or produce... to summon staff. This requirement was not met as evidenced by: Based on the failed testing of call bell and pendant on 3/10/2026 of R1 the licensee did not ensure the facility’s call pendants were operational; therefore facility was unable to perform timely response, including providing timely continence care. This is a potential risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Jul 9, 2026

Plan of correction: Licensee to ensure call signal system is working correctly by submitting proof of a system test by July 13, 2026.

Type of visit: Case Management - Legal/Non-compliance

At approximately 9:20 AM Licensing Program Analyst (LPA) Nakagawa arrived unannounced to conduct a Non-Compliance Conference (NCC) inspection and was greeted by the Resident Care Coordinator who showed LPA to General Manager Kathy Neeser to advise of today's inspection. Administrator Fernando Valadez arrived shortly to further assist with today's NCC inspection. The facility was put on an NCC plan for 2 years ending on 04/29/2028 to bring the facility into compliance. The purpose of today's inspection was to follow up on areas of prior concern in the operation of the facility operation identified by the department including, but not limited to: Ensure that all staff are trained on basic first aid per regulation Ensure that all staff are trained in the needs and services of residents, including the special needs of residents (including swallowing issues and other dietary needs) LPA toured the facility and found the building and grounds to be clean and well-maintained. A tour of the hospice unit found the care staff to be attentive and familiar with the special needs of the hospice residents, including any swallowing issues and/or dietary needs. An inspection of the dining room found a caregiver on duty during lunch. Administrator stated that a care staff is in attendance during all meals to aid in any dietary needs. LPA reviewed the training records of med. techs and care coordinators of all departments and found all to have current first aid/CPR certification. The facility uses an on-line course for all staff. In addition, an in-person training was held on 5/7/2026 for all staff. (Continued on 809-C) (Continued from 809) Trainings for all staff were held on 5/6/2026 for swallowing needs and modified diets by a registered dietician from Nutricopia, the company that provides their dietary information and trainings. No deficiencies were found at the time of inspection. No citations issued. Report reviewed with Administrator.the state’s words, verbatim · CDSS document, Jul 2, 2026

Allegation investigated: Staff does not seek medical attention for resident in a timely manner Staff mismanages residents' medications. Staff does not ensure incident reports are being reported. Staff does not ensure facility operates in ratio.

On 04/29/2026 Licensing Program Analyst (LPA) Nakagawa met with Administrators Fernando Valadez and Kathy Neeser in the Regional Office to complete the complaint investigation regarding the above allegations. The complaint alleges that Staff does not seek medical attention for resident in a timely manner. The complainant believes that med techs are instructing care staff to pick up fallen residents from the floor, and med techs not evaluating said fallen residents; rather when residents are evaluated, emergency services such as EMS and Fire are not contacted for professional services. Based on the review of incident reports and staff interviews, LPA found that it is well-understood by staff and med techs that it isrequired by facility to call 911 for any unwitnessed fall, injury or other condition requiring an immediate medical assessment, therefore the allegation that Staff does not seek medical attention for resident in a timely manner is unsubstantiated. Continued on 9099-C..... Unsubstantiated Continued from 9099.... The complaint alleges that “Staff does not ensure incident reports are being reported”. The complainant states that the Staff are not appropriately reporting incidents. Complainant states that staff (S1) is willingly reading and disposing of Incident Reports constructed by care staff. LPA reviewed incident reports submitted and found that through October and November of 2025 there were 7 incident reports submitted; 5 were death reports, 1 was a resident requiring medical treatment and 1 was for a fall. LPA spoke with 8 staff members: 8 of 8 staff members stated that they do not believe staff/med techs/Administrator are ignoring their reporting of incidents nor is the Administrator disposing of incident reports that staff are submitting. Based on the interviews conducted and review of Incident Reports submitted the allegation that staff does not ensure incident reports are being reported is unsubstantiated. Although the allegation may have occurred there is not a preponderance of evidence therefore the allegation is unsubstantiated. The complaint alleges “Staff does not ensure facility operates in ratio”. The facility staff schedule shows coverage in Assisted Living, Memory Care and Hospice units. LPA also discussed staffing with Administrator who stated that call-offs are covered by Administrator and/or Directors to ensure adequate coverage. A review of staff schedules shows that there are 2 to 3 care staff and one med technician scheduled in memory care per shift, 1 care giver for the hospice wing per shift and 2 to 3 care staff for the Assisted Living with the med technician depending on the shift. This facility is licensed as a Residential Care Facility for the Elderly (RCFE) and Title 22 Regulations does not require any staffing ratio. Regulations for RCFE’s state that staff provides adequate care and supervision. The complainant stated that California Code of Regulations (22 CCR)§ 87865.1 (for residential care facilities for the chronically ill) requires ratios, however this facility is not a residential care facility for the chronically ill and therefore this regulation does not apply. The allegation that “Staff does not ensure facility operates in ratio” is unsubstantiated. Although the allegation may have occurred there is not a preponderance of evidence. The Complaint alleges that “Staff mismanages residents' medications”. The complainant states that med techs are not properly utilizing hand over hand method when administering medications; as well as not administering medications in a timely manner." LPA conducted interviews with 4 med techs and asked them to explain the hand-over-hand technique. 4 of 4 med technicians were able to demonstrate the correct method. LPA also asked them to explain what they would do if the resident was unable to participate in the hand over hand method and 4 of 4 responded that they would call hospice to administer the medications because they are only allowed to assist. The complainant also stated that medications were not administered in a timely manner. A review of the Medication Administration Records (MARs) indicate that medications were administered as per doctors’ orders. Based on interviews with staff and review of medication administration records the allegation that “Staff mismanaged residents’ medications” is unsubstantiated. Although the allegation may have occurred there is not a preponderance of evidence therefore the allegation is unsubstantiated.the state’s words, verbatim · CDSS document, Apr 29, 2026 · control 21-AS-20251113112003

Allegation investigated: Staff did not medically intervene/perform basic first aid for resident resulting in resident's death.

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 (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)the state’s words, verbatim · CDSS document, Apr 29, 2026 · control 21-AS-20251118151726

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.269(a)(6) · Plan of correction due date: Apr 29, 2026

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: 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.the state’s words, verbatim · CDSS document, Apr 29, 2026

Plan of correction: 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.

Type of visit: Case Management - Legal/Non-compliance

A Non-Compliance Conference (NCC) was conducted today in the Santa Rosa Regional Office. Present in the meeting was: Licensing Program Managers Kimberley Mota and Bethany Moellers, Licensing Program Analyst (LPA) Jill Nakagawa and Facility Administrators Fernando Valadez and Kathy Neeser. The purpose of today's office meeting was to discuss areas of concern in the facility operation identified by the Department and placing The Californian facility on a Non-Compliance Conference (NCC) plan. Parties present during the meeting agreed to a NCC plan for two years beginning 04/29/26 to bring the facility, The Californian into compliance. Items addressed during the meeting include, but are not limited to: · Licensee will ensure that all staff are trained on basic first 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.the state’s words, verbatim · CDSS document, Apr 29, 2026

Type of visit: Required - 1 Year

On October 17, 2025 Licensing Program Analyst (LPA) Nakagawa conducted an unannounced Annual Required – 1 yr. Inspection at The Californian and met with Administrator Fernando Valadez. There are 74 residents in care. LPA arrived at the facility and was greeted by the receptionist and Administrator. LPA did a review of 5 resident and 5 staff files and found them to be complete. Overall, the facility was clean and a comfortable temperature. An inspection of the facility's dining room found the room clean, well-organized and seating was well-spaced for easy access for those residents in wheelchairs and walkers. It was decorated for the Fall/Halloween season and a display of staff and resident-decorated pumpkins. The kitchen was clean, well-organized and sanitary. There was an ample supply of perishable and nonperishable food as required per Title 22 regulation. The kitchen also stored a large supply of emergency supplies. All exits were clear and free from obstructions. Stairwells were also clear and had evacuation chairs stationed at the top of each stairwell. Fire extinguishers were found to be last serviced on 06/20/2025 and fully charged at the time of the visit. A fire drill was conducted for each shift on 07/31/2025 and the facility participated in the Statewide Earthquake drill, the Great Shake on 10/16/2025. The next drill is scheduled to be held prior to the end of November. Continued on 809-C... Continued from 809... The Generations Grove (memory care unit) has locked cabinets in each room for controlled items. Each resident in Generations Grove has access to a secure area outside for exercise, visitations and activities. There was a supply of hygiene products and paper products available for clients. All clients' bedrooms have lighting & appropriate furnishings. Bathrooms were outfitted with grab bars and non-slip mats. The grounds provide plenty of space for outdoor activities. There are shaded walkways and benches, and the front entrance has couches and music playing for residents' enjoyment. The back yard has a little fenced barnyard with chickens which the residents enjoy. The activities program is quite busy with monthly big-group activities which include the families and community. The program also has a gym, games, ice cream socials and happy hours in addition to the daily games and music programs. An activity calendar is posted. LPA requested the following: Updated LIC500 Proof of Liability Insurance No deficiencies found at the time of inspection. No citations issued.the state’s words, verbatim · CDSS document, Oct 17, 2025

Allegation investigated: Personal rights

This is an amended version of a report signed on 07/24/2025. Licensing Program Analyst Jill Nakagawa arrived unannounced to conduct investigation and deliver amended findings regarding the above allegation. LPA met with Administrator Fernando Valadez. The complaint alleges that Resident (R1’s) personal rights were violated. The complainant states medications that should have been ordered through the VA (Veterans Administration) at no cost to R1 were ordered through another pharmacy which incurred out of pocket costs. Continued on 9099-C Unsubstantiated Continued from 9099... This is an amended report from 07/24/2025. LPA discovered through interviews that due to a supply issue the Licensee was unable to obtain medications through the VA and used another pharmacy which was authorized by R1's responsible party signing a Pharmacy Agreement on 06/22/2023. LPA found the Licensee paid the responsible party $961.63 for the costs incurred as a courtesy. Based on the signed Pharmacy Agreement the allegation that resident’s personal rights were violated is unsubstantiated. Continued from 9099A A review of the Electronic Medication Administration Record (EMAR) shows that it was updated by facility staff (S1) and verified by (S2) on the same day to reflect the change. Electronic Medication Administration Records (EMAR) indicate that the medication Mirtazapine was discontinued on June 27, 2024, by VA (Veterans Administration) staff. On September 7, 2024 (R1) received a new order re-starting Mirtazapine (same dosage) by their physician, not with the VA. EMAR records show medication being administered the same day as order received. On December 27, 2024, R1 received a new order for Mirtazapine under a new physician’s order, which is indicated in the EMAR. In addition, the complainant stated that R1 received an additional flu vaccine after receiving one from a care provider. Facility was provided a standing order signed by a physician for a yearly flu vaccine. Staff (S3) stated that a call to responsible party approved the administration of the vaccine. R1 received the flu shot on November 25, 2024, at 10 AM based on the medical information they had. It was not until later, upon receiving a bill for the vaccine that it was discovered that R1 had already received a vaccine from their care team prior to the November 25, 2024 vaccine, however that information had not been given to the facility. Based on medical, pharmacy and medication administration records, the allegation that the Licensee did not follow physician’s orders is unsubstantiated. Although the allegation may have occurred there is not a preponderance of evidence therefore the allegation is unsubstantiated.the state’s words, verbatim · CDSS document, Jul 24, 2025 · control 21-AS-20250312135607

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(16) · Plan of correction due date: Jul 24, 2025

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:(16)To receive or reject medical care or other services. This requirement was not met as evidenced by: Based on financial statement for R1, the Licensee did not comply with R1’s requested medical services and R1 incurring uncovered medical expenses which poses a potential risk to the health, safety or personal rights risk to residents.the state’s words, verbatim · CDSS document, Jul 24, 2025

Plan of correction: Administrator to submit a written plan to CCL on how they will ensure that billing procedures regarding medications will be followed by 07/29/2025.

Allegation investigated: Staff did not abide to the admission agreement Staff is overcharging for services not received Staff mishandled a resident's medication Staff did not provide adequate care and supervision to the residents Staff did not provide healthful and comfortable accommodations for a resident Staff did not safeguard a resident's personal belongings Staff did not ensure a resident attended scheduled appointments Staff did not ensure a resident received therapy while in care

On 5/22/2025 Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to continue the complaint investigation and to deliver findings regarding the above allegations. LPA Nakagawa met with Administrator Fernando Valadez. LPA toured the facility, reviewed resident records, made observations, interviewed staff and outside parties during the course of the investigation. The complaint alleges that the Staff did not abide by the admission agreement; stating that resident (R1) moved out of the facility on 9/30/2024, but continued to be billed for monthly rent and cable for October 2024. Based on a review of resident R1’s admissions agreement signed by R1’s responsible party, states a 30-day notice must be given prior to move-out. Records indicate R1 vacated the facility on 9/30/2024 but a 30-day notice was not given to the facility, therefore the allegation that the staff did not abide by the admission agreement is unsubstantiated. Continued on 9099-C..... Unsubstantiated Continued from 9099..... The complaint alleges that Staff is overcharging for services not received. Based on review of R1’s admissions agreement, services are all inclusive; there is no breakdown in charges for particular services therefore the allegation that Staff is overcharging for services not received is unsubstantiated. The complaint alleges that Staff did not ensure a resident attended scheduled appointment; stating that the facility did not take R1 to scheduled appointments on 9/4/24 and 9/20/24. The complainant stated that staff (S1) was told about the appointments. LPA interviewed S1 who stated that they were unaware of the appointments. LPA also audited the appointment system which runs through the Reception Desk. The system found two appointments listed for 9/19/24 and 10/02/24 (note says family is taking). Neither of the dates match those of the missed appointments. LPA was unable to corroborate the allegation therefore the allegation that Staff do not ensure resident attended scheduled appointments is unsubstantiated. As there is a lack of evidence to substantiate that Staff were aware of appointments, there is not enough corroborating evidence to support the allegation that Staff caused R1 not to receive therapy while in care. Although the allegations may have happened there is not a preponderance of evidence to substantiate the allegations therefore the allegations are unsubstantiated. Continued on 9099-C.2 Continued from 9099-C The complaint alleges that Staff did not provide adequate care and supervision to the residents; Staff did not provide healthful and comfortable accommodations for a resident; and, Staff did not safeguard a resident's personal belongings. LPA requested care notes for R1 during their time in Memory Care. LPA found no incident reports regarding R1. LPA found no indications that R1 was hurt and review of Inventory List which was signed by responsible party but no belongings were documented and there were no belongings reported as stolen. Therefore the allegations are unsubstantiated. Although the allegations may have happened there is not a preponderance of evidence to substantiate the allegations therefore the allegations are unsubstantiated. Finally, the complaint alleges that Staff mishandled a resident's medication; stating that a medication technician gave R1 the wrong medication and reported the error to doctor. Records of dispensed medications were reviewed and no error was found. Interviews were conducted but unable to corroborate the allegation. Although the allegation may have happened there is not a preponderance of evidence to substantiate the allegation therefore the allegation is unsubstantiated.the state’s words, verbatim · CDSS document, May 22, 2025 · control 21-AS-20250122122628

Type of visit: Case Management - Incident

At approximately 10:05 AM, Licensing Program Analyst (LPA) Nakagawa arrived unannounced to conduct a Case Management - Incident Visit and met with Administrator, Fernando Valadez. The purpose of the visit was to follow up on a self-reported incident that was submitted to Community Care Licensing (CCL). CCL received an incident report on 05/13/2025. The report stated that on 05/11/2025, Resident (R1), who has a diagnosis of dementia and is unable to leave facility unassisted, eloped from community. Staff became aware of R1's absence at 7:30 PM; Administrator, police and family were notified. At approximately 7:40 PM R1's family notified community that R1 had walked to his home and was safe. Administrator went to location of R1. R1 was not in need of medical attention so Administrator transported R1 back to community. Per R1’s Physician’s Report (LIC602) R1 is diagnosed with dementia and is unable to leave the facility unassisted. (Deficiency cited) Civil Penalty for $500.00 was issued during today's visit for Zero Tolerance, Absence of Supervision. See LIC809-D for Deficiency. Exit interview conducted with Administrator and a copy of this report along with LIC811 (Confidential Names) was provided.the state’s words, verbatim · CDSS document, May 22, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: May 22, 2025

87411(a) Personnel Requirements - General Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidence by: Based on incident report and interview, facility failed to provide supervision to R1 resulting in an elopement. The absence of supervision is an immediate risk to the Health, Safety and Rights of resident in care.the state’s words, verbatim · CDSS document, May 22, 2025

Plan of correction: Administrator submitted proof to CCL on 5/22/2025 re: conducting ongoing in-service training about elopement procedures., and will self-certify that landscaping and fence have been modified to prevent climbing. ****A civil penalty is being assessed for $500.00.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to The Californian to check on the Activities Program in Memory Care. LPA Nakagawa inspected the facility with Administrator Fernando Valadez and found it to be clean and well-organized. The facility was a comfortable temperature. There were 28 residents in the memory care unit (Generations) and there were 3 staff on site. Memory Care has one full time and one 1/2 time Activities staff person. There is also one dedicated housekeeper and meals are served by dietary staff. A majority of residents were engaged in table-top activities at the time of inspection. No deficiencies found at the time of inspection. No citations issued.the state’s words, verbatim · CDSS document, Apr 15, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Nakagawa arrived unannounced to conduct a case management visit regarding a police report for Case# CV2024-217 filed by staff member S1 alleging sexual misconduct by S2. The facility was able to provide video surveillance and other evidence which Woodland Police reviewed. District Attorney did not file any charges. S1 and S2 are no longer employees at the facility due to attendance issues. No citations were issuedthe state’s words, verbatim · CDSS document, Jan 23, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jill Nakagawa conducted an unannounced Annual Required – 1 yr. Inspection at The Californian and met with Administrator Fernando Valadez. There were 90 residents present. LPA arrived at the facility and was greeted by Administrator, Resident Care Coordinator and receptionist. LPA was shown the facility which was found to be clean and at a comfortable temperature with all exits free from obstruction. Clients' bedrooms, common areas, kitchen & food storage areas were inspected. Fire extinguishers were found to be last serviced on 07/20/2024 and fully charged at the time of the visit. A Fire Alarm and Sprinkler System Inspection was completed on 10/24/2024 and the system was found to within acceptable results. A fire drill was conducted for each shift on June 21, 2024. The next drill is scheduled to be held prior to the end of November. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator and freezer were properly stored as per regulations on this day at the time of the visit. Toxins and cleaning supplies are locked in storage cabinets. The Generations Grove (memory care unit) has locked cabinets in each room for controlled items. There was a supply of hygiene products and paper products available for clients. All clients' bedrooms have lighting & appropriate furnishings. LPA found the water temperature in 10 out of 10 rooms to be within 105 and 120 F, which is within regulation. Bathrooms were outfitted with grab bars and non-slip mats. The dining rooms were clean and provided adequate seating (AL and Memory Care). The grounds provide plenty of space for outdoor activities. There are shaded walkways and benches, and the front entrance has couches and music playing for residents' enjoyment. Continued on 809-C Continued from 809..... The Activities Department offers games and other entertainment 7 days a week, and had the facility decorated for the Harvest season. LPA found residents to be engaged in activities throughout the community, including exercise class and a visit from podiatry. The hospice unit had its own caregiver, along with a resident therapy pet, which the residents found very endearing and comforting. LPA reviewed 5 resident files and 5 personnel files and found them to be complete. There were no deficiencies found at the time of inspection. No citations were issued.the state’s words, verbatim · CDSS document, Nov 15, 2024

Allegation investigated: Facility is in disrepair Staff did not respond to resident's call for assistance in a timely manner Staff mismanaged resident's medication

Licensing Program Analyst (LPA) Jill Nakagawa arrived at The Californian on 10/24/2024 to complete an investigation and deliver findings on the above allegations. The complaint alleges that at the time Resident (R1) moved into the facility, the air-conditioning in R1’s apartment was not functioning. Portable air-conditioners were provided to R1. Outside temperatures ranged from 89 degrees to 105 degrees per Accuweather records. On September 3, 2024 a maintenance log shows the toilet seat was loose and shifting, and on September 7, 2024 the maintenance log shows that the service pull cord had to be switched due to R1 not being able to pull cord. Continued on 9099-C... Substantiated Continued from 9099.... Based on LPA’s review of records and interviews, the preponderance of evidence standard has been met, therefore the allegation that the facility was in disrepair is substantiated. California Code of Regulations, (Title 22, Division 6 & Chapter 8), are being cited on the attached LIC 9099D.”) The complaint alleges that R1 attempted to make contact with staff by pulling the emergency cord in their apartment, but it was broken and reported to staff on September 7, 2024. R1 then used their emergency necklace and staff did not respond for over 30 minutes. LPA reviewed call bell records and found that call bell response times for R1 on September 7, 2024 were not answered in a timely manner, taking 20-40 minutes to be answered on three calls. Based on interviews conducted and records reviewed the preponderance of evidence standard has been met, therefore the allegation that staff did not respond to resident’s call for assistance in a timely manner is found to be Substantiated. California Code of Regulations, (Title 22, Division and Chapter #) are being cited on the attached 9099D. The complaint alleges that staff attempted to administer medication to R1 that was not prescribed by R1’s physician. Staff acknowledged the medication error after R1 refused the medication. Based on interviews conducted the preponderance of evidence standard has been met, therefore the allegation that staff mismanaged resident’s medication is found to be Substantiated. California Code of Regulations, (Title 22, Division 6 and Chapter 8) are being cited on the attached 9099D.)the state’s words, verbatim · CDSS document, Oct 24, 2024 · control 21-AS-20240912175632

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Oct 24, 2024

87303(a)87303 Maintenance and Operation (a) The facility shall be clean, safe... in good repair at all times. Maintenance shall include provision of maintenance services... well-being of residents, employees and visitor. This was not met as evidenced by: Based on maintenance records and interviews the facility did not ensure that facility was within regulation due to air conditioner toilet and pull cord needing repairs. This is a potential risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Oct 24, 2024

Plan of correction: Administrator has submitted written plan of action to ensure units are ready for resident move-ins to LPA on 10/24/2024.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Oct 24, 2024

87411(a) Facility personnel shall at all times be sufficient in numbers & competent to provide the services necessary to meet resident needs…This requirement has not been met as evidence by:** Based on records review of alarm response system and interviewsAdministrator did not ensure that staff on duty responded in a timely manner to call system to assist residents in care. Some call bell response times for R1 were 20- 40 minutes, which poses an immediate risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Oct 24, 2024

Plan of correction: Licensee failed to ensure staff responded appropriately to call bell system and meet resident care needs in a timely manner. Licensee shall conduct staff training on how call bells will be responded to and provide a 7 day alarm response log to Licensing by 10/25/24 along with training plan. Verification of training by POC due date 10/30/2024.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(5) · Plan of correction due date: Oct 24, 2024

Incidental Medical and Dental Care Services.(a) The licensee shall assist residents with self-administered medications when needed. This requirement is not met as evdenced by: Based on interviews and record review, staff attempted to administer the wrong medication to the wrong resident, which is an immediate risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Oct 24, 2024

Plan of correction: Administrator agrees to ensure staff have additional medication training on the 7 Rights of Medication Administration before passing medication. Administrator to submit plan of training by 10/26/2024 and proof of training of staff handling medications by 10/30/2024.

Allegation investigated: Staff did not comply with Infection control requirements

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 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.the state’s words, verbatim · CDSS document, Sep 4, 2024 · control 21-AS-20240514153351

Allegation investigated: Staff do not ensure that resident is provided assistance. Staff left residents in soiled clothing. Staff did not provide adequate food service to resident in care. Staff do not administer residents' medications as prescribed.

Licensing Program Analyst (LPA) Nakagawa met with Administrator Kathy Neeser for the purpose of delivering findings on the above captioned allegations. This investigation included interviews with witnesses: staff and other parties, as well as records and document reviews, photos and LPA observations. The following determinations were made: On August 7, 2024 LPA made an unannounced visit to the facility and inspected the Memory Care unit and found 33 residents, 2 care staff. There was one med tech. who came and went but did not provide care, only medication management, and one housekeeper. LPA found many residents sitting in the hallway and several residents in bed requesting care. LPA went into a resident’s room who requested help with consumption of a protein drink. LPA rang the bell for assistance without any response after 15 minutes. LPA notified the Administrator who found that the call bells were inoperable. LPA requested call bell records to verify response times but records unavailable due to a malfunction in the software program. Based on the time the LPA waited for someone to come and help the resident, the lack of a working call bell system and the staff scheduling for the unit the preponderance of evidence standard has been met therefore the Dept. finds the allegations that staff do not ensure that resident is provided assistance and staff did not provide adequate food service to resident in care is SUBSTANTIATED. Continued on 9099-C Substantiated In addition, the complaint alleges that staff left residents in soiled clothing. LPA reviewed photos of R1 in only a diaper, which R1 was pulling apart. Based upon photos, records reviewed and statements taken from witnesses, the preponderance of evidence standard has been met. Therefore, the allegation that staff left residents in soiled clothing is SUBSTANTIATED. The complaint also alleges that staff do not administer resident's medications as prescribed. LPA's review of resident R1's MAR lacks documentation and shows that medications were not given as ordered by the Physician. Based on LPA interviews, and review of information obtained, the investigation has revealed that the allegation staff failed to administer resident's medication as prescribed is SUBSTANTIATED. 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 and appeal of rights provided.the state’s words, verbatim · CDSS document, Sep 4, 2024 · control 21-AS-20240523134233

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(a) · Plan of correction due date: Sep 4, 2024

87555 General Food Service Requirements (a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner. Based upon LPA's observations Licensee did not provide adequate assistance in serving food in a safe and healthful manner. This requirement is not evidenced by : Based on LPA observation of resident unable to receive assistance.This is an immediate risk to the Health, Safety and Rights of residents in care.the state’s words, verbatim · CDSS document, Sep 4, 2024

Plan of correction: Licensee to ensure that staff understand the importance of meeting the dietary needs of the residents by conducting a training on the Regulation 87555. Administrator to provide a date of training by 9/5//2024. Proof of training (sign-in sheet) and training materialsto be submitted to LPA by 09/12/2024.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Sep 4, 2024

87411(a) Personnel Requirements – General- (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by: Based on LPA observation, interview and record review residents were not able to receive care in a timely manner. This is an immediate risk to the Health, Safety and Rights of residents in care.the state’s words, verbatim · CDSS document, Sep 4, 2024

Plan of correction: Licensee to ensure staff are sufficient in numbers to meet the needs of residents. Licensee agrees to submit updated staffing schedule, showing 24-hour coverage to meet the needs of residents. Updated staffing schedule to be submitted to CCL by POC date of COB 09/05/2024..

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(c)(2) · Plan of correction due date: Sep 4, 2024

Incidental Medical and Dental Care (c) (2)- Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by LPA's review of records and interviews. The LPA reviewed records, and conducted interviews with staff. The investigation revealed that R1 had a medicated patch ordered to be applied in AM and removed in PM. MAR shows patch applied but documentation for removal was missing several entries. This is a potential health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Sep 4, 2024

Plan of correction: Administrator to ensure that the facility staff that handle medication assistance to residents in care are in-serviced on Medication Policies of the facility in regards to medication orders and documentation of medication assistance. Submit plan of training by 9/5/2024. Please submit proof of training (sign-in sheet) and copy of training materials by 9/15/2024.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced for a case management visit. LPA met with Kathy Neeser, to review incident of resident R1 leaving the facility unattended. Facility was clean, orderly and a comfortable temperature. LPA and Administrator discussed staffing additions that have occurred and additional trainings that will occur to ensure the safety and well-being of residents. Related deficiencies were cited in a complaint investigation during same visit. No other citations issued.the state’s words, verbatim · CDSS document, Sep 4, 2024

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced for a case management visit. LPA was greeted at door by receptionist who asked LPA to sign visitor's log before allowing entry to the facility. The LPA met with Fernando Valadez, Administrator, and toured the facility to inspect the facility and observe staffing and review records. The facility was found to be clean and orderly. Lunch was observed and residents expressed their satisfaction in the menu, including desserts. Several activities were observed during visit. No citations issued at the time of inspection.the state’s words, verbatim · CDSS document, Aug 7, 2024