Court Opinion

ID: 4562019
Source: CourtListenerOpinion
Date Created: 2020-09-01 19:02:20.865746+00
Date Added: 2024-06-11T08:46:20.654108
License: Public Domain

Filed 9/1/20 IV Solutions v. Cal. Board of Pharmacy CA2/4
              NOT TO BE PUBLISHED IN THE OFFICIAL REPORTS

California Rules of Court, rule 8.1115(a), prohibits courts and parties from citing or relying on opinions not certified for
publication or ordered published, except as specified by rule 8.1115(b). This opinion has not been certified for publication
or ordered published for purposes of rule 8.1115.

         IN THE COURT OF APPEAL OF THE STATE OF CALIFORNIA

                                  SECOND APPELLATE DISTRICT

                                                DIVISION FOUR

IV SOLUTIONS, INC., et al.,                                           B281845

         Plaintiffs and Appellants,                                   (Los Angeles County
                                                                       Super. Ct. No. BS160527)
         v.

CALIFORNIA BOARD OF
PHARMACY,

         Defendant and Respondent.

         APPEAL from a judgment of the Superior Court for Los Angeles
County, Amy D. Hogue, Judge. Affirmed.
         Wolf, Rifkin, Shapiro, Schulman & Rabkin, Jason M. Flom and
Marc E. Rohatiner for Plaintiffs and Appellants.
         Xavier Becerra, Attorney General, Carl W. Sonne, Assistant
Attorney General, Shawn Paul Cook and Matthew A. King, Deputy
Attorneys General, for Defendant and Respondent.
      Following a lengthy administrative hearing, respondent California
Board of Pharmacy (the Board) revoked the pharmacy license issued to
appellant IV Solutions, Inc. (IVS), and ordered that IVS and its
president, Alireza Varastehpour, also known as Alex Vara (we will refer
to him as Vara; we refer to IVS and Vara together as IVS/Vara), are
prohibited from serving as a manager, administrator, owner, member,
officer, director, associate, or partner of a licensee of the Board.
IVS/Vara filed in the superior court a petition for writ of administrative
mandamus. Finding the weight of the evidence supported the Board’s
findings and that the Board did not abuse its discretion in imposing the
penalty, the superior court denied the petition. IVS/Vara appeal,
arguing that (1) the Board applied an incorrect standard of proof;
(2) certain findings of the Board were not supported by the weight of the
evidence; and (3) the Board abused its discretion by imposing the most
severe penalty. None of these arguments have merit. Accordingly, we
affirm the judgment.

                              BACKGROUND
      IVS is a closed-door clinical pharmacy that provides home infusion
therapy to patients.1 Vara, who has a background in marketing and
business development for healthcare-related companies, created IVS
and is its president and sole owner. The Board issued a pharmacy
permit to IVS, with Vara as president, in 2002.

1     A closed-door pharmacy is a pharmacy that provides products and
services only to its select clients, and is not open to the general public.

                                       2
     As part of its business, IVS compounds sterile injectable products.
At the time of the events at issue here, a pharmacy that did sterile
compounding was required to either have a sterile compounding permit
issued by the Board or be accredited by a Board-approved accrediting
agency. IVS performed sterile compounding under an accreditation
from the Joint Commission on Accreditation of Healthcare
Organizations (now known as the Joint Commission), a Board-approved
agency.
     During the relevant time, IVS employed 15 to 20 people. Vara,
who is not a pharmacist, was in charge of business development, and
Marlene Casillas, the chief operating officer, was in charge of human
resources, billing, and business operations (although the evidence
showed that Vara often made decisions regarding IVS’s business
operations). The “Pharmacist In Charge” (PIC) was in charge of
prescriptions and the clinical aspects of the pharmacy. At least 12
different people served as PIC between 2002 and 2014. From February
2009 until March 2012, the PIC was Renee Sadow, who was a party to
the administrative proceeding at issue here but is not a party to this
appeal.

A.   Initial Complaint, Investigation, and Accusation
     In February 2008, the Board received a complaint from IVS’s
former PIC, who had left his employment with IVS after a disagreement
with Vara regarding the acquisition of the prescription medication
Lovenox. Two Board investigators investigated the complaint. During
the course of that investigation they discovered, among other things,

                                    3
that (1) Vara had a key to the pharmacy (as opposed to the business
office) in his possession;2 (2) IVS staff had been using the name “Stat
Clinical Pharmacy” on documentation relating to several patients;3
(3) Vara had obtained Lovenox from a company in Canada that was not
licensed to sell wholesale prescription medications in California; and
(4) some vials of Lovenox, which Vara had obtained from a different
unlicensed wholesaler, had been shipped to Vara’s father’s home, i.e., an
unlicensed facility.
     The Board filed an accusation against IVS, with Vara as its
president, alleging eight causes for discipline related to the above
discoveries and other issues discovered during the inspection of IVS’s
records.

B.   Patient Complaints and Amended Accusations
     While the former PIC’s complaint was being investigated, and
after the initial accusation was filed, the Board received additional
complaints related to several of IVS’s patients.

     1.    Patient D.K.
     In April 2010, patient D.K. was prescribed a six-week regimen of
an antibiotic to be administered intravenously 24 hours a day, with a

2     As a non-pharmacist, Vara was not permitted to have a key to the
pharmacy. The key was required to be kept in a sealed envelope signed by
the pharmacist who last used it, and the pharmacy could not be opened
without a pharmacist present.

3    No permit had been issued to operate a pharmacy under that name.

                                     4
specific dosage delivered every six hours by a prism infusion pump.
Sadow, IVS’s PIC, filled the prescription and programmed a Curlin
4000 CMS pump—an ambulatory infusion pump that may be obtained
only by prescription from a licensed practitioner—to provide the
required doses. IVS delivered the pump, medication, and supplies to
D.K.
       IVS contracted with another company to provide a nurse to set up
the pump, start the intravenous line, and show D.K. and his family how
to change the IV bags of medication. The first nurse visited D.K. every
day for the first few days, and then was replaced by a different nurse.
       On the eighth day of D.K.’s therapy, which was a Friday, that
replacement nurse started a new IV bag early in the afternoon. That
evening, after the nurse had left, the alarm on the pump went off and
would not stop, so members of D.K.’s family called the nursing
company. The supervisor of the nursing company, who was unable to
reach the nurse assigned to D.K., spoke with D.K.’s family members
that night, but was unable to resolve the issue.
       When D.K.’s son-in-law, Kevin G., checked in on D.K. at around
11:00 p.m. that night, the IV bag appeared to be full. When Kevin
checked on D.K. early the next morning, the IV bag was empty.
Because he believed the IV bag had been changed less than 12 hours
before, Kevin was afraid that D.K. had received the full 24-hour cycle of
the medication in much less than 24 hours. Kevin tried to call the
nurse assigned to D.K., but was not able to reach her, so he called his
mother, Donna G. (who is a registered nurse), who came and checked on
D.K.

                                    5
     In the meantime, the nursing company contacted IVS at 4:49 a.m.
that morning. At 4:50 a.m., PIC Sadow received a call from IVS’s
answering service, telling her that a member of D.K.’s family had called
requesting a nurse. Sadow was on vacation, and had received
permission from Vara and Casillas to have Jeannie Kim be the on-call
pharmacist while she was away. Therefore, Sadow told the answering
service to contact the pharmacist on call, i.e., Kim.
     At 8:57 a.m., Sadow called Vara to tell him about the call she had
received; she confirmed that she was away for the weekend and that
Jeanie Kim was the pharmacist on call. She told Vara that either Kim
or the nurse assigned to D.K. should be involved in the situation. Over
the course of the morning and early afternoon, Kevin and Donna called
IVS and spoke to Vara several times, complaining about the pump and
asking for a new one. Vara repeatedly told them there was nothing
wrong with the pump and blamed the assigned nurse for the problem
they were experiencing. When Donna asked to speak to a pharmacist,
Vara told her that he was the owner of the pharmacy and was the
appropriate person to deal with the situation. During some of Vara’s
conversations with Kevin and Donna, Vara cursed at them and hung up
on them.4
     Eventually, after speaking with a technician from the pump
manufacturer, Vara concluded that there was nothing wrong with the
pump, and that the nurse assigned to D.K. had done something that

4     For example, Vara told Kevin to “go fuck yourself and hire an
attorney,” and told Donna, “I don’t give a shit.”

                                      6
caused the problem. He arranged for a different nurse (D.K.’s first
nurse, who had done the original set up) to go to D.K.’s home to try to
fix the problem. That nurse arrived at 6:00 p.m. that evening and, after
speaking with a technician from the manufacturer, was able to
reprogram the pump.
      Although the pump subsequently worked without incident, D.K.’s
family decided to take him off the IV regimen due to the problems they
encountered. They also filed a complaint with the Board about
IVS/Vara. During the investigation of that complaint, the Board
investigator obtained documents from IVS that showed that, on more
than one occasion, IVS used prescription labels identifying the
pharmacy as “IV Solutions Clinical Pharmacy,” even though it was not
licensed to do business under that name.

      2.    First Amended Accusation
      Following the investigation of D.K.’s family’s complaint, the Board
filed a first amended accusation. The amended accusation added PIC
Sadow as a respondent5 and added nine causes for discipline (for a total
of 17 causes). Three of the added causes related to allegations that
Vara performed duties of a pharmacist (or represented himself as a
pharmacist) without being licensed as a pharmacist when he dealt with
the problem involving the prescription-required Curlin pump. One

5     Because Sadow is not a party to this appeal, our discussion will not
address any allegations or findings made as to her unless necessary for
context.

                                      7
added cause was based upon IVS’s use of “IV Solutions Clinical
Pharmacy” on some labels. The remaining additional causes also
related to issues arising from the services provided to D.K. and/or the
investigation of his family’s complaint.

     3.    Patient C.R.
     Patient C.R. was scheduled to have foot surgery. In anticipation
of the surgery, her surgeon prescribed antibiotics and morphine, to be
administered by an infusion pump, after C.R. was released from the
hospital following the surgery; the surgeon requested that IVS provide
the home infusion services. IVS determined it would use a Curlin pump
similar to the one used with patient D.K.
     IVS contracted with Care South Home Health Service (Care
South) to provide nursing services in connection with the infusion.
Stephanie Phillips, a Care South manager, previously had asked IVS to
provide training to Care South nurses on how to use the Curlin pump,
because the nurses were not familiar with it. Although IVS has written
policies and procedures that it will provide staff that is properly trained
and competent to set up home medical equipment and to instruct the
patient and/or caregiver on its use, Vara refused Phillips’s request.
Instead, Vara gave Care South a DVD from the manufacturer that
demonstrated how to use the pump.
     The medications, equipment, and supplies prescribed for C.R.
were delivered to her home before the surgery. The morning C.R. was
released from the hospital, a nurse from Care South arrived at C.R.’s
house, set up the infusion equipment, and started the antibiotic

                                     8
therapy. C.R., who had been administered pain medication at the
hospital, told the nurse that she was not in pain, so she did not need
any morphine right then.
      Early the next morning, which was a Saturday, C.R. began
experiencing increasing pain in her foot. When the Care South nurse (a
different nurse than the one who had set up the equipment the day
before) arrived at 9:00 a.m., C.R. asked her to give her morphine. The
nurse, who had been instructed to, and did, view the DVD from the
Curlin pump manufacturer the day before, began to set up the
morphine IV. Before starting to administer the drug, however, she told
C.R. that she needed to check on something because she was not
familiar with the Curlin pump. The nurse tried to call IVS, using all of
the telephone numbers she had for it, but no one answered.6 C.R. and
her husband also tried several times to call IVS at the phone number
provided to them, but they were unable to speak to anyone or leave a
message. The nurse then called her manager, Phillips, who also tried to
call IVS at all the phone numbers she had for it, but no one answered
her calls. As a result of everyone’s inability to reach anyone at IVS,
C.R. had to forego the IV morphine and instead took oral pain
medication.

6      IVS has a written policy that at least one pharmacist will be available
at all times. IVS’s procedures require that an employee be responsible for
forwarding calls to an answering service at the end of each business day, and
that the person on call after close of business check the answering service for
messages periodically.

                                       9
     Phillips continued to try to call IVS, and finally reached Vara two
days later (on Monday). When Phillips told him about being unable to
reach anyone, Vara told him that IVS’s phone had been out all
weekend, and that he was unaware of it until he arrived at the office
that day. The following day (Tuesday), C.R. called IVS and said she
wanted to speak with someone in charge. Vara got on the phone, and
C.R. told him what had happened on Saturday, and how no one could
reach anyone at IVS; Vara did not believe her, and implied that she was
lying.
     After C.R. was finished with her antibiotic treatment, IVS came
and picked up its equipment. C.R. still had the full bag of morphine, so
IVS took that as well. She asked IVS for a refund for the cost of the
morphine she returned to IVS because she was unable to use it, but she
received no response. She subsequently received a billing invoice from
IVS that seemed to indicate that IVS had billed her for three bags of
morphine even though it had delivered only one bag to her, which she
had not been able to use.
     C.R. submitted a complaint to the Board. The investigator
assigned to the complaint obtained the records from IVS’s answering
service, which showed no calls were received on the Saturday in
question, and that the service did not begin receiving calls until 10:00
a.m. on the following day. The investigator concluded that IVS’s staff
forgot to transfer the phone system to the answering service when IVS
closed its office on that Friday evening.
     In the course of her investigation of the incident, the Board
investigator discovered that from around January 2009 to January

                                    10
2012, IVS had on at least 38 occasions obtained Curlin Medical 4000
CMS pumps from a wholesaler not licensed to sell or rent such devices
in California.7 That wholesaler, Ardus Medical (Ardus), was based in
Ohio, where it was not required to have a license to supply Curlin
pumps to persons or entities in that state. Neither Ardus nor IVS staff
were aware that a license was required under California law.

     4.    Patient J.M.
     J.M. was diagnosed with Hepatitis C in 2009. His physician
prescribed an IV regimen of several drugs, to be administered for a
year, to try to keep J.M. from having to have a liver transplant. The
physician referred J.M.’s IV treatment to IVS even though IVS was not
in J.M.’s insurer’s network of providers. Neither the physician nor IVS
told J.M. or his wife that IVS was out of network. Nor did IVS tell J.M.
or his wife, before services were rendered, what the cost of care,
anticipated charges to J.M., or co-insurance amount would be.
     IVS delivered the first round of supplies and medications on
November 6, 2009. Sometime before January 29, 2010, IVS billed J.M.’s
health insurer for the treatments provided from November 7, 2009
through January 4, 2010. The insurer issued to J.M. an explanation of
benefit payments (EOB) on January 29, 2010, showing that IVS billed
$14,922 during that time period, and that the insurer agreed to pay

7     IVS was not permitted to purchase or lease any device designated as
dangerous, such as the Curlin pump, from a person or entity not licensed
with the Board as a wholesaler or pharmacy. (Bus. & Prof. Code, § 4169,
subd. (a)(1).)

                                     11
only $21.67. Alarmed, J.M. called IVS. She talked to an employee who
told her there had been a “coding error” and that it would be fixed. She
did not receive any bills from IVS or EOBs after that until January
2011.
        J.M. continued to receive treatments from IVS through September
2010; he had to discontinue treatment at that time due to side effects of
the medication. IVS did not send bills to J.M.’s insurer for those
treatments until January 2011; J.M. received the EOBs related to those
bills in late January and early February 2011. Those EOBs showed
that IVS had billed the insurer more than $2 million for J.M.’s
treatment. Along with the EOBs, the insurer sent reimbursement
checks, payable to J.M.’s wife, totaling approximately $900,000, i.e., the
amount the insurer agreed to pay on the $2 million of claims IVS
submitted.
        J.M.’s wife, who is an insurance investigator (for a different
insurance company), believed the amounts IVS billed were excessive, so
she conducted research into the average wholesale prices of the
medications at issue and the amount that would be charged by an in-
network retail pharmacy (Walgreens). She found that IVS charged
$1,967,683 for medications for which Walgreens charges $62,599.60.
        J.M.’s wife submitted complaints to her insurer and the Board.
She also contacted IVS to complain about the excessive charges, and
because she was worried that she (and/or her family) would be
responsible for the $1.1 million in charges that were not covered by her
insurance. The IVS staff to whom J.M.’s wife spoke told her that IVS
would only seek payment from the insurer, and demanded that she sign

                                      12
the $900,000 in checks she received over to IVS. J.M.’s wife told them
that before she would do that, she wanted to see the itemized bills for
the medications and services that were rendered to J.M. IVS’s chief
operating officer, Casillas, told her that IVS did not have itemized
statements. Instead, Casillas offered to meet with her to go through the
bills that IVS sent to the insurer and compare them to the EOBs. When
J.M.’s wife continued to demand itemized bills and refused to turn over
the checks, IVS filed a civil lawsuit against her and J.M., seeking more
than $2 million.8

      5.    Patient R.M.
      R.M. had a series of serious problems with his knees beginning in
2003, many of which resulted in infections that required IV antibiotic
treatment. With respect to one of those treatments, in 2008, the
pharmacy that supplied the medication billed R.M.’s insurer $20,000,
and with respect to another, in 2009, the pharmacy billed the insurer
$18,000; both were six-week treatments. In each case, the antibiotic
treatments were provided by pharmacies within R.M.’s health
insurance company’s network.
      In 2011, R.M. had another infection after a procedure on his knee,
and his physician ordered a five week IV antibiotic treatment. The
physician referred R.M. to IVS for the treatment. IVS was not an in-

8      The parties ultimately submitted the dispute to arbitration and settled
their claims, with J.M. paying IVS $710,000, and the rest of the insurance
proceeds going to pay J.M.’s and his wife’s attorney fees.

                                      13
network provider for R.M., and neither R.M.’s physician nor IVS told
R.M. that IVS was out of network. IVS also did not disclose to R.M.
before the treatment started (or at any time thereafter) the cost of the
treatment, the anticipated charges to him, or his co-payment.
     IVS provided the IV antibiotics to R.M. from April 22, 2011 to May
28, 2011. It billed R.M.’s insurer $12,755 for each day’s medication, for
a total of $471,935. The cost to IVS for the medication given to R.M.
was less than $200 per day, for a total cost of less than $7,000 for the
entire five weeks of treatment. IVS did not begin to submit bills for the
treatment to R.M.’s insurer until at least May 25, 2011, when the
treatment was almost completed; the insurer did not issue EOBs until
late June 2011.
     Although R.M.’s insurer paid almost all of the amounts IVS billed,
R.M. was upset when he saw the EOBs. He believed IVS had
committed fraud, and he would have stopped treatment with IVS and
gone to a different provider had he seen the EOBs earlier. He contacted
the fraud department of his insurer and various news media
organizations, and ultimately filed a complaint with the Board.

     6.    Second and Third Amended Accusations
     The Board filed a second amended accusation that added four
causes for discipline arising from the investigations of C.R.’s, J.M.’s,
and R.M.’s complaints. The first additional cause alleged that IVS/Vara
engaged in unprofessional and deceptive conduct by failing to inform
J.M. and R.M. that IVS was an out-of-network provider, failing to
inform them of the cost of treatment, and by delaying billing the

                                     14
patients’ insurers until the end of their treatments. The second
additional cause alleged that IVS/Vara obtained dangerous devices
(Curlin pumps) from an unlicensed wholesaler. The third additional
cause alleged that IVS/Vara failed to have consultation available to C.R.
regarding the Curlin pump, and the last additional cause alleged that
IVS/Vara created a false document by issuing a receipt stating that IVS
delivered three bags of morphine to C.R. when only one had been
delivered.
     During the administrative hearing, the Board filed a third
amended accusation in which certain allegations (not relevant to this
appeal) were deleted, but the causes and all other allegations remained
unchanged.

C.   Administrative Hearing and Findings of Administrative Law
     Judge

     The administrative hearing was held over 23 days, beginning on
July 8, 2014 and ending on September 18, 2014. On March 5, 2015, the
administrative law judge (ALJ) issued a proposed decision with
extensive factual findings and legal conclusions. In the legal
conclusions portion of the proposed decision, the ALJ began with a
discussion of the applicable standards of proof. The ALJ concluded that
a governing agency seeking disciplinary action against a professional
license was required to establish cause for discipline by clear and
convincing evidence (citing Ettinger v. Board of Medical Quality
Assurance (1982) 135 Cal. App. 3d 853, 857), but that only a
preponderance of the evidence is required to establish a cause for

                                    15
discipline against a nonprofessional license (citing Imports Performance
v. Department of Consumer Affairs, Bureau of Automotive Repair (2011)
201 Cal. App. 4th 911, 916-917; San Benito Foods v. Veneman (1996) 50
Cal. App. 4th 1889). The ALJ concluded that the clear and convincing
evidence standard applied to PIC Sadow because she possessed a
professional license, i.e., one that requires extensive education,
training, and testing requirements. However, the ALJ concluded that
IVS/Vara had a nonprofessional license—based upon undisputed
evidence that anyone meeting certain basic criteria is able to obtain a
pharmacy permit9—and therefore the lower preponderance of the
evidence standard applied to IVS/Vara. Despite these conclusions, the
ALJ clarified that all factual findings, “including any factual findings
involving Respondent IV Solutions and/or Mr. Vara but not Respondent
Sadow,” were established by clear and convincing evidence, except
where expressly stated to have been established by a preponderance of
the evidence.
     Turning to the allegations of the accusation, the ALJ found the
Board had established 12 of the 19 alleged causes for discipline against
IVS (and Vara as president),10 as follows:

9     The ALF observed that an inspector for the Board credibly testified
that an applicant for a pharmacy permit needs only to complete a financial
affidavit and attest that he or she has not been convicted of a felony or
misdemeanor related to drugs, and has not been arrested for driving under
the influence of alcohol; there are no educational requirements, and no
testing or expertise is required.

10  Although there were 21 causes for discipline alleged in the third
amended accusation, one (the 11th cause) was alleged only against PIC

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     • First cause for discipline: Moral turpitude, dishonesty, fraud,
       deceit, or corruption. The ALJ found the Board established by a
       preponderance of the evidence that IVS “intentionally acted in a
       deceitful manner as to patients J.M. and R.M. by concealing
       information from them that it had a duty to provide”—i.e., IVS
       failed to disclose the cost of the treatments and services at the
       outset, as required by IVS’s written policies, and intentionally
       delayed billing J.M.’s insurer so as not to alert him or his wife of
       the charges—and that IVS’s conduct was motivated by a desire to
       maximize charges to the patients’ insurers. The ALJ concluded
       that this conduct subjected IVS to disciplinary action under
       Business and Professions Code11 section 4301, subdivision (f).
     • Second cause for discipline. Obtaining a dangerous device from an
       unlicensed wholesaler. The ALJ found by clear and convincing
       evidence that IVS/Vara violated section 4169, subdivision (a)(1) by
       obtaining Curlin 4000 CMS pumps from an unlicensed wholesaler.
       The ALJ found that as a result of this violation, IVS/Vara are
       subject to disciplinary action for unprofessional conduct under
       section 4301, subdivisions (j), (o), and (p).
     • Third cause for discipline. Performing the duties of a pharmacist
       without a license. The ALJ found that Vara, a non-pharmacist,

Sadow, and another (the 13th cause) was withdrawn at the hearing. The
ALJ found that the 5th, 8th, 9th, 10th, 18th, 19th, and 20th causes for
discipline were not established.

11    Further undesignated statutory references are to the Business and
Professions Code.

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    performed the duties of a registered pharmacist by responding to
    calls from members of D.K.’s family regarding the prescription
    Curlin pump IVS had provided, and making the decision, without
    the involvement of a licensed pharmacist, not to replace the pump.
    The ALJ concluded, based on this conduct, that IVS/Vara was
    subject to disciplinary action for unprofessional conduct under
    section 4301, subdivisions (j), (o), and (p) for violating California
    Code of Regulations, title 16, section 1793.1, subdivision (b).
• Fourth cause for discipline. Performing the duties of a pharmacist
    without a license. Based upon the same facts as found in
    connection with the third cause for discipline, the ALJ found that
    IVS/Vara was subject to disciplinary action for unprofessional
    conduct under section 4301, subdivisions (f), (j), (o), and (p) for
    violating California Code of Regulations, title 16, section 1793.1,
    subdivision (g).
•   Sixth cause for discipline. False and misleading label on
    prescription. The ALJ found by clear and convincing evidence that
    IVS is subject to disciplinary action for unprofessional conduct
    under section 4301, subdivisions (f), (j), (o), and (p) for violating
    section 4078, subdivision (a)(1), and section 4076, subdivision
    (a)(6), by using prescription labels on certain prescriptions that
    falsely represented the name of the pharmacy as “IV Solutions
    Clinical Pharmacy.”
• Seventh cause for discipline. Records of dangerous drugs and
    devices kept open for inspection. The ALJ found by clear and

                                    18
  convincing evidence that IVS is subject to disciplinary action for
  unprofessional conduct under section 4301, subdivisions (j), (o),
  and (p) for violating section 4081, subdivisions (a) and (b) by
  failing to provide a certain requested document to a Board
  inspector.
• Twelfth cause for discipline. Failure to have consultation
  available. The ALJ found that IVS violated California Code of
  Regulations, title 16, section 1751.6, subdivision (a) by not being
  available for consultation with C.R. or her nurse regarding the use
  of the Curlin pump, which prevented C.R. from receiving the
  morphine she was prescribed. For this reason, the ALJ concluded
  that IVS is subject to disciplinary action for unprofessional
  conduct under section 4301, subdivisions (j), (o), and (p).
• Fourteenth cause for discipline. Making of false documents. The
  ALJ found that IVS/Vara are subject to disciplinary action under
  section 4301, subdivisions (f) and (g) for falsely representing “Stat
  Clinical Pharmacy” as a licensed pharmacy when providing
  pharmacy services to approximately 25 patients, and creating and
  receiving documentation using that name.
• Fifteenth cause for discipline. Violation of state law governing
  pharmacy/receiving and holding misbranded dangerous drugs.
  The ALJ found that IVS violated Health and Safety Code section
  111440 by importing vials of Lovenox, a dangerous drug, that
  were misbranded and restricted to sales in Canada. Therefore,
  the ALJ concluded that IVS is subject to disciplinary action for

                                 19
  unprofessional conduct under section 4301, subdivisions (i) and
  (o).
• Sixteenth cause for discipline. Noncompliant ordering and
  delivery to an unlicensed facility. The ALJ found that IVS violated
  section 4059.5, subdivision (a) by ordering Lovenox, a dangerous
  drug, from an unlicensed wholesaler in Canada and having it
  delivered to Vara’s father’s house, an unlicensed facility. This
  conduct rendered IVS subject to disciplinary action for
  unprofessional conduct under section 4301, subdivisions (j) and
  (o).
• Seventeenth cause for discipline. Noncompliant Security. The
  ALJ found that Vara was in personal possession of the pharmacy
  key on February 29, 2008, in violation of California Code of
  Regulations, title 16, section 1714, subdivisions (d) and (e). As a
  result, IVS is subject to disciplinary action for unprofessional
  conduct under section 4301, subdivisions (j) and (o).
• Twenty-first cause for discipline. Noncompliant refilling of
  controlled substance. The ALJ found that IVS violated Health and
  Safety Code section 11200, subdivision (c), by refilling a Schedule
  II controlled substance, and therefore is subject to disciplinary
  action for unprofessional conduct under section 4301, subdivisions
  (j) and (o). (This violation was discovered when the pharmacy
  inspector reviewed IVS’s records during his investigation of the
  complaint from the former PIC.)

                                20
      Turning to the disposition, the ALJ considered the Board’s
“Disciplinary Guidelines [Rev. 10/2007]” (the Guidelines) as required by
section 1760 of title 16 of the California Code of Regulations. Those
Guidelines set forth four categories of violations (with corresponding
ranges of discipline), with Category I as the least serious and Category
IV as the most serious. The ALJ found there were two Category I
violations (the 17th and 21st causes for discipline), two Category II
violations (the 1st and 14th causes for discipline), three Category III
violations (the 7th, 15th, and 16th causes for discipline), and five
violations that could be classified as either Category II or III, depending
on the circumstances (2nd, 3rd, 4th, 6th, and 12th causes for discipline).
However, as directed by the Guidelines—which provide that where
there are multiple violations in more than one category, the
recommended discipline is the discipline recommended for the highest
category—the ALJ treated “the totality of the violations” by IVS as
Category III for the purpose of considering the range of recommended
discipline.12
      The ALJ next addressed the 15 factors listed in the Guidelines as
factors to be considered in determining whether to impose the
minimum, maximum, or some intermediate penalty. After addressing
each of those factors, the ALJ concluded: “It is abundantly clear that
Respondent IV Solutions was the moving force behind all of the

12     The minimum recommended discipline for a single Category III
violation is revocation, with revocation stayed, 90 days actual suspension,
and three to five years probation. The maximum recommended discipline is
revocation.

                                     21
violations established in this case. Most of those violations were serious
and intentional, the result of dishonesty, deceit or a conscious decision
by Mr. Vara to exclude pharmacists from their required duties. Those
violations subjected the public to the potential of harm and actually
resulted in harm to some patients. While it is true that Respondent IV
Solutions has no prior disciplinary record with the Board, it had only
been licensed for about six years when it began engaging in misconduct
and it had received three citations. Moreover, the violations established
in this case were various, consistent and pervasive, spanning from 2008
through 2011 (about the time that the initial accusation was brought).
Some mitigating facts were presented, mainly that Respondent IV
Solutions cooperated with the Board’s investigations and some of the
violations were inadvertent. However, the mitigating facts are counter-
balanced by aggravating facts, and substantially outweighed by the
level of intentional and calculated misconduct. Most glaring is the
absence of rehabilitation evidence. Given the breadth and span of the
misconduct established, it was incumbent on Respondent IV Solutions
to demonstrate some level of acceptance, contrition and dedication to
preventing such misconduct in the future. The record is bereft of any
hint that Mr. Vara believes he has done much if anything wrong and
that similar misconduct in the future will be avoided. Finally, although
the prices charged to J.M. and R.M. were not illegal or the basis for
discipline, they certainly were unsavory. Since revocation is the
maximum discipline recommended for a Category III violation, and
Respondent IV Solutions has done little to show that the public will be

                                    22
adequately protected by being placed on probation, revocation is
warranted in this case.”
     The ALJ’s proposed order therefore revoked IVS’s pharmacy
permit and ordered that IVS/Vara be prohibited from serving as a
manager, administrator, owner, member, officer, director, associate, or
partner of a Board Licensee.

D.   Decision of the Board
     The ALJ’s proposed decision was submitted to the Board, which
adopted it, to become effective on April 30, 2015. On April 20, 2015,
IVS requested a stay to allow it to file a petition for reconsideration.
The Board granted the stay, and subsequently granted IVS’s petition
for reconsideration.
     On reconsideration, the Board read and considered the entire
record, including the parties’ written submissions, as well as the
transcript and exhibits from the administrative hearing. The Board
addressed IVS’s assertion that the ALJ had applied an incorrect
standard of proof, and that the clear and convincing evidence standard
applied to IVS/Vara as well as Sadow. The Board rejected this
assertion, and found the ALJ properly found the preponderance of the
evidence standard applied. Nevertheless, the Board concluded, based
upon its “close review of the record,” that each cause of discipline was
proven by clear and convincing evidence. Accordingly, it modified
certain findings and conclusions in the proposed decision (i.e., those
findings and conclusions stating they were established by a
preponderance of the evidence) to state they were established by clear

                                     23
and convincing evidence. In doing so, the Board stated, “Respondent IV
Solutions acted with repeated disregard for professional, ethical and
honest practices. Reviewed collectively, the facts and circumstances of
the misconduct are overwhelmingly persuasive.”
     Finally, the Board addressed the appropriateness of the proposed
penalty. It observed that the Board is statutorily required to place
protection of the public as its highest priority. (Citing § 4001.1.) Citing
the harm caused by IVS/Vara’s conduct with regard to C.R., J.M., and
R.M., the Board stated that IVS, “especially through the conduct of Mr.
Vara as its owner, has completely eroded the Board’s confidence in its
ability to lawfully operate a pharmacy,” and that IVS’s “violations
demonstrate such a pattern of willful disregard for the laws pertaining
to operating a pharmacy that [IVS] should no longer be able to do so.”
     The Board adopted the ALJ’s proposed decision, as modified to
state that all factual findings and legal conclusions were established by
clear and convincing evidence.

E.   Petition for Writ of Administrative Mandamus
     1.    The Petition and Motion for Writ
     IVS/Vara filed in the superior court a petition for writ of
administrative mandamus under Code of Civil Procedure section
1094.5. In their memorandum of points and authorities in support of
their motion for a peremptory writ, they argued that the ALJ and the
Board applied an incorrect standard of proof, challenged the sustaining
of the first, third, fourth, and sixth causes for discipline, and raised
issues regarding the punishment the Board imposed.

                                     24
     Specifically, they argued that the Board failed to follow its
precedent when it applied the preponderance of the evidence standard
to the causes against IVS rather than the clear and convincing evidence
standard. With regard to the first cause for discipline, they contended
(1) the Board improperly based its decision on IVS’s failure to follow its
own voluntarily adopted internal policies (that it would disclose to the
patient the expected costs of treatment prior to rendering services, etc.);
and (2) there was no evidence that IVS intentionally delayed submitting
its bills to J.M.’s insurer until after his treatment had been completed.
With regard to the third and fourth causes for discipline, IVS/Vara
asserted that neither the Board’s findings nor the evidence supported
the Board’s conclusion that Vara performed the duties of a pharmacist.
And they argued that the Board erred in sustaining the sixth cause for
discipline because there was no evidence that IVS/Vara intended to
deceive by using the name “IV Solutions Clinical Pharmacy” on some
prescription labels.
     Addressing the Board’s selection of revocation as the punishment,
IVS/Vara raised four issues. First, they argued that the Board
committed clear legal error by considering evidence related to the prices
IVS charged certain patients in determining the appropriate
punishment, because the Board has no jurisdiction over drug prices.
Second, they asserted the Board applied its Guidelines incorrectly by
categorizing several violations as more severe than authorized by the
Guidelines and treating all violations as Category III in determining
the punishment. Third, they contended the Board erred in finding they
had not submitted any evidence of rehabilitation in determining

                                    25
punishment. Finally, they argued the Board incorrectly concluded that
much of their conduct was knowing and intentional; they contend
instead that most of the conduct was inadvertent and harmless.

     2.    Trial Court’s Ruling
     The trial court found the weight of the evidence supported the
Board’s decision, and that the Board did not abuse its discretion in
revoking IVS’s license.
     The court rejected the argument that the clear and convincing
evidence standard of proof applied to the determination whether to
revoke IVS’s pharmacy permit. It agreed with the ALJ’s analysis that,
because a pharmacy permit does not require the applicant to complete
extensive educational, training, and testing requirements, proceedings
to suspend or revoke the permit do not require the higher standard of
proof applicable to proceedings involving professional licenses.
Accordingly, the court found that the ALJ properly applied the
preponderance of the evidence standard.
     The trial court also rejected IVS/Vara’s challenge to the first cause
for discipline. As discussed in more detail in section C.2.b. of the
Discussion, post, the court found that the ALJ properly considered IVS’s
failure to follow its own policies because the court concluded that IVS’s
conduct—adopting those policies to obtain accreditation from the Joint
Commission but then propounding different policies with lower
standards after accreditation was obtained—falls within the broad
range of section 4301, subdivision (f)’s definition of “unprofessional
conduct.” The court also set forth extensive evidence presented at the

                                    26
administrative hearing from which the ALJ reasonably concluded that
IVS delayed billing J.M.’s insurance company to avoid alerting J.M.’s
wife to the amounts it was charging.
      Similarly, and as discussed more fully in section C.3. of the
Discussion, post, the trial court set forth the evidence presented at the
administrative hearing regarding the conversations Vara had with
D.K.’s family and caretakers regarding the problem with the Curlin
pump (during which, the ALJ found, Vara improperly performed the
duties of a pharmacist), and concluded the weight of the evidence
supported the sustaining of the third and fourth causes for discipline.
      The trial court also rejected IVS/Vara’s challenge to the sustaining
of the sixth cause for discipline. The court observed that there was no
authority for IVS/Vara’s assertion that the Board must find they
intended to deceive by using the false name “IV Solutions Clinical
Pharmacy.” Instead, the court found that IVS’s use of that unlicensed
name was a statutory violation that is a cause for discipline under
several subdivisions of section 4301, regardless of intent.
      Of the four challenges IVS/Vara raised to the penalty imposed, the
trial court agreed with one. The court agreed that the Board
improperly characterized the second, third, fourth, sixth, and twelfth
causes for discipline as Category II/III violations when they should have
been characterized as Category II violations. However, the court found
this was not grounds for remand because IVS/Vara had committed
multiple violations, some of which were in Category III, so the Board
properly considered the range of penalties recommended for Category
III violations.

                                    27
     The trial court rejected IVS/Vara’s remaining challenges. It found
that the ALJ’s consideration of IVS’s prices in the context of
understanding IVS’s motives was appropriate. In also found that,
contrary to IVS/Vara’s assertion, the ALJ did consider evidence they
point to as evidence of rehabilitation, but the court agreed with the
ALJ’s determination that there was little evidence that IVS was doing
things differently or that Vara accepted responsibility for his
misconduct. Finally, although the court acknowledged that some of the
violations at issue might have been inadvertent, it found that many
were “quite serious.” It concluded that, viewed as a whole, the
numerous violations found to have occurred “suggest either a disregard
for or lack of knowledge about the laws regulating pharmacies.”
Therefore, the court found that the Board did not abuse its discretion in
determining “that IVS’s numerous violations and ‘unscrupulous
conduct’ warranted revocation of its license.”
     The trial court denied the petition for writ of mandate, and
entered judgment in favor of the Board. IVS/Vara timely filed a notice
of appeal from the judgment.

                             DISCUSSION
A.   Governing Law
     Pharmacies and pharmacists in California are governed by the
Pharmacy Law (§§ 4000 et seq.), which includes provisions related to

                                    28
licensing, practices allowed (or disallowed), and discipline.13
Administration and enforcement of the Pharmacy Law is vested in the
Board. (§ 4001, subd. (a).) As part of its administration of the
Pharmacy Law, the Board has authority to adopt rules and regulations
as necessary to protect the public. (§ 4005.) In exercising its licensing,
regulatory, and disciplinary functions, “[p]rotection of the public shall
be the [Board’s] highest priority.” (§ 4001.1.)
       The Pharmacy Law provides that “[e]very license issued may be
suspended or revoked” (§ 4300, subd. (a)), and requires the Board to
“take action against any holder of a license who is guilty of
unprofessional conduct” (§ 4301). Section 4301 lists several examples of
unprofessional conduct, including:
     • “The commission of any act involving moral turpitude, dishonesty,
       fraud, deceit, or corruption, whether the act is committed in the
       course of relations as a licensee or otherwise, and whether the act
       is a felony or misdemeanor or not.” (§ 4301, subd. (f).)
     • “Knowingly making or signing any certificate or other document
       that falsely represents the existence or nonexistence of a state of
       facts.” (§ 4301, subd. (g).)

13    “Pharmacy” is defined as an area, place, or premises licensed by the
Board in which the profession of pharmacy is practiced. (§ 4037.) A
“pharmacist” is defined as a natural person to whom a license has been
issued by the Board in accordance with section 4200, who is entitled to
practice pharmacy within or outside of a licensed pharmacy. (§ 4036.)
Section 4200 lists the several requirements for a person to be licensed as a
pharmacist, including educational requirements, practical experience, and
testing requirements; there are no such requirements for obtaining a
pharmacy license.

                                      29
     • “The violation of any of the statutes of this state, of any other
       state, or of the United States regulating controlled substances and
       dangerous drugs.” (§ 4301, subd. (j).)
     • “Violating or attempting to violate, directly or indirectly, . . . any
       provision or term of this chapter or of the applicable federal and
       state laws and regulations governing pharmacy.” (§ 4301, subd.
       (o).)
     • “Actions or conduct that would have warranted denial of a
       license.” (§ 4301, subd. (p).)
       Proceedings to suspend or revoke a license issued by the Board
must be conducted in an administrative adjudication in accordance with
Government Code section 11500 et seq. The Board’s action resulting
from that adjudication is subject to review by the superior court by
means of a petition for writ of administrative mandamus under Code of
Civil Procedure section 1094.5. (§ 4300, subd. (e).)

B.     Standards of Review Governing Petitions for Writ of
       Administrative Mandamus

       When a party files a petition for writ administrative mandamus
challenging an adjudicatory decision, the inquiry by the trial court is
limited “to the questions whether the [administrative agency] has
proceeded without, or in excess of, jurisdiction; whether there was a fair
trial; and whether there was any prejudicial abuse of discretion. Abuse
of discretion is established if the [administrative agency] has not
proceeded in the manner required by law, the order or decision is not

                                        30
supported by the findings, or the findings are not supported by the
evidence.” (Code Civ. Proc., § 1094.5, subd. (b).) “Where it is claimed
that the findings are not supported by the evidence, in cases in which
the court is authorized by law to exercise its independent judgment on
the evidence, abuse of discretion is established if the court determines
that the findings are not supported by the weight of the evidence.”
(Code Civ. Proc., § 1094.5, subd. (c).)
     When the administrative decision at issue affects a fundamental
vested right made by an administrative agency—such as a decision to
suspend or revoke an existing license, as in the present case—the trial
court “‘exercises its independent judgment upon the evidence disclosed
in a limited trial de novo in which the court must examine the
administrative record for errors of law and exercise its independent
judgment upon the evidence.’ [Citation.] But in doing so, ‘a trial court
must afford a strong presumption of correctness concerning the
administrative findings, and the party challenging the administrative
decision bears the burden of convincing the court that the
administrative findings are contrary to the weight of the evidence.’
[Citation.]” (Hoang v. California State Bd. of Pharmacy (2014) 230
Cal. App. 4th 448, 455.)
     On appeal, even when the trial court is required to review the
administrative decision under the independent judgment standard of
review, we review the trial court’s determination that the weight of the
evidence supports the administrative decision under the substantial
evidence standard of review. (Fukuda v. City of Angels (1999) 20
Cal. 4th 805, 823 (Fukuda).) Where the trial court decides a question of

                                     31
law, we exercise our independent judgment. (Department of Health
Care Services v. Office of Administrative Hearings (2016) 6 Cal. App. 5th
120, 140.) And when the petitioning party challenges the penalty
imposed by the administrative agency, we review de novo whether the
agency’s imposition of that penalty constituted an abuse of discretion by
the agency. (Cassidy v. California Bd. of Accountancy (2013) 220
Cal. App. 4th 620, 627.) “But we will not disturb the agency’s choice of
penalty absent ‘“an arbitrary, capricious or patently abusive exercise of
discretion”’ by the administrative agency.” (Id. at pp. 627-628.)

C.   Arguments on Appeal
     IVS/Vara raise essentially the same issues on appeal that they
raised in the trial court.14 They contend (1) the Board applied the
incorrect standard of proof; (2) the Board improperly relied upon IVS’s
billing practices and its internal policies in sustaining the first cause for
discipline; (3) the weight of the evidence did not support the Board’s
finding that Vara performed the duties of a pharmacist (the third and
fourth causes for discipline); (4) the Board improperly sustained the
sixth cause for discipline because there was no evidence that IVS
intended to deceive when it used the name “IV Solutions Clinical
Pharmacy” on some documents or supplies; and (5) the Board abused its

14     At oral argument, IVS/Vara’s counsel noted that he had overlooked that
the ALJ did not apply the preponderance of the evidence standard to all of
the findings regarding IVS/Vara, but he argued that to the extent the ALJ
did apply that standard, it was error.

                                     32
discretion in choosing revocation of IVS’s license as the punishment.
None of their arguments prevail.

     1.    Standard of Proof at Administrative Hearing
     IVS/Vara argue that the Board improperly “applied a
preponderance of the evidence standard as opposed to the much more
stringent clear and convincing standard.” This argument ignores the
actual findings of the Board.
     It is true that the Board agreed with the ALJ’s determination that
the appropriate standard of proof applicable to an administrative
revocation proceeding involving a pharmacy is the preponderance of the
evidence standard. But the Board concluded, after considering the
entire record, that “regardless of the applicable standard of proof, each
cause of action found to be proved in the Proposed Decision . . . was, in
this case, proven by clear and convincing evidence.” Then, in adopting
the ALJ’s proposed decision, the Board expressly modified the ALJ’s
findings and conclusions to state that all findings and conclusions were
established by clear and convincing evidence.
     In sum, because the Board found that all of the findings and
conclusions were established by clear and convincing evidence, we need
not address IVS/Vara’s argument that such a standard of proof was
required in this case.

     2.    First Cause for Discipline
     The first cause for discipline relates to the complaints filed by
patients J.M. and R.M. The accusation alleged that IVS engaged in

                                    33
conduct that involved “moral turpitude, dishonesty, fraud, deceit, or
corruption” (§ 4301, subd. (f)) with regard to those patients.

            a.    The Board’s Findings and Conclusions
      The Board found, by clear and convincing evidence,15 that IVS had
a duty to disclose its pricing and billing information to J.M. and R.M.
but intentionally failed to do so. It found that the duty to disclose was
created when IVS developed written policies and procedures (P&Ps),
which were required for IVS to be accredited by the Joint Commission,
and that IVS needed that accreditation to do sterile compounding
without a Board permit.16
      The P&Ps at issue required IVS to disclose to J.M. and R.M., at
the outset of services and thereafter, the costs of care for which they
would be responsible, the potential for insurance reimbursement, and
their financial obligations for items not reimbursed by insurance. The
P&Ps also required IVS to provide to each patient an itemized
explanation of charges and a written explanation of the cost of care and
the patient’s responsibility for those costs; they also required that an

15    As noted, although the ALJ’s proposed decision made this finding by a
preponderance of the evidence, when the Board adopted the proposed
decision after granting IVS’s motion for rehearing it modified the findings to
the extent the decision stated they were found by a preponderance of the
evidence and found they were established by clear and convincing evidence.

16   At the time the events at issue took place, IVS could not do sterile
compounding unless it was accredited by the Joint Commission or another
approved organization, or obtained a sterile compounding license from the
Board.

                                      34
IVS employee or agent explain these rights and obligations to the
patient.
     The Board found that IVS intentionally withheld this information
from J.M. and R.M. It also found that IVS exacerbated this situation by
creating and giving paperwork to the patients stating that IVS would
provide some of this information to them only if they were going to be
held financially responsible for some or all of the charges. IVS also
required the patients to sign a document that included an agreement to
be financially responsible for any costs not reimbursed by insurance. In
other words, IVS’s own paperwork was contrary to its P&Ps.
     The Board noted that IVS was not required to disclose to J.M. or
R.M. that it was an out-of-network provider under its P&Ps or any
other general duty. But it observed that IVS’s out-of-network status
allowed it to charge significantly more for its drugs than it could have
charged had it been in-network, which the Board determined provided
the motive for IVS to not provide the information required by its P&Ps:
if J.M. and R.M. had been given that information they likely would have
complained about IVS’s “exorbitant prices” and immediately stopped
using IVS for the treatments. In fact, the Board found that IVS
intentionally delayed and withheld most of its bills for J.M.’s treatment
until after the treatment had been completed, so as not to alert J.M.’s
wife about its charges before the insurer made its reimbursement
decisions. And, although the Board acknowledged that a showing of
damages, injury, or harm to the patients was not required, it found that
both patients suffered harm, including that IVS’s charges exhausted or
seriously depleted the patients’ lifetime maximum insurance benefit

                                    35
amount, even though both of them were likely to need significant
medical services in the future.
      The Board thus concluded that clear and convincing evidence
established that IVS “intentionally acted in a deceitful manner as to
patients J.M. and R.M. by concealing information from them that it had
a duty to provide, which conduct was motivated by a desire to maximize
charges to the patients’ insurance companies. By engaging in such
conduct, [IVS] acted contrary to justice, honesty, modesty or good
morals, which constitutes moral turpitude. For those reasons, it was
established by [clear and convincing] evidence that [IVS] violated
section 4301, subdivision (f).”

            b.    The Trial Court’s Ruling
      In its ruling denying IVS/Vara’s writ petition, the trial court found
that the Board17 properly relied upon IVS’s failure to disclose the costs
of care and its delayed billing in concluding that IVS violated section
4301, subdivision (f).

                  i.     Failure to Disclose Cost of Care
      Addressing IVS/Vara’s contention that the Board improperly
based its conclusion on evidence that IVS failed to abide by its own

17    We note that throughout its ruling the trial court generally refers to
“the ALJ’s” findings and decision, even though it is the Board’s findings and
decision that is subject to review. The trial court’s references to the ALJ’s
findings and decision has no effect on the analysis, however, since the Board
adopted those findings and decision (with the modification that all findings
and conclusions were established by clear and convincing evidence).

                                      36
internal policies, the trial court found that IVS’s conduct fell within the
broad range of conduct described in section 4301, subdivision (f), i.e.,
“act[s] involving moral turpitude, dishonesty, fraud, deceit, or
corruption.”
     The court pointed to testimony by the Board’s expert witness, Dr.
John D. Jones, that IVS adopted certain P&Ps as part of the process of
accreditation by the Joint Commission, and that obtaining that
accreditation confers advantages because many prescribers only refer
patients to pharmacies that are accredited by the Joint Commission.
The court noted that the P&Ps IVS adopted for accreditation included a
“Patient Bill of Rights and Responsibilities” that stated, in relevant
part: “As a home care patient you have the right to: [¶] . . . [¶] Be
informed in advance of potential reimbursement for services under
Medicare, Medicaid, or other third party insurers based on your
condition and insurance, of any financial obligations for services not
fully reimbursed, and to be notified of any changes in charges for which
you may be liable during the course of care and service[;] [¶] [and]
[r]eceive an itemized explanation of charges.”
     But the court observed that the document entitled “Patient’s
Rights and Responsibilities” that IVS gave to J.M and R.M. stated only
that “[a]s a client you have the right to: [¶] . . . [¶] Know in advance if
you will be responsible for any cost other than your co-payment and
yearly deductible that are predetermined by your medical insurance
policy and Medicare/Medi-Cal regulations.” In addition, the court cited
to testimony by Casillas, IVS’s chief financial officer, that it was IVS’s
policy not to disclose that it was an out-of-network pharmacy or to

                                     37
disclose in advance the amount it would bill to the patient’s insurer.
The court also noted that IVS required patients to sign a form that
included the following statement: “I understand that I am personally
and financially responsible for all billed charges, including interest, and
late fees’ [sic] for all products and services provided by IVS that are for
any reason whatsoever not reimbursed by my insurance, or
Medicare/MediCal/CalOptima.”
     Based on this evidence, the trial court concluded that the Board’s
reliance upon IVS’s failure to disclose its costs of care to J.M. and R.M.
in finding that IVS engaged in unprofessional conduct was proper. The
court observed that the language of the statute permits the Board to
take disciplinary action against a licensee for a wide range of
“unprofessional conduct,” regardless whether that conduct violates a
law or regulation. And the court found that IVS’s conduct in this
instance—adopting disclosure requirements in order to receive the
accreditation it needed to do sterile compounding (and which conferred
significant advantages) but then adopting practices that do not provide
those disclosures—“falls within the broad range of ‘act[s] involving
moral turpitude, dishonesty, fraud, deceit, or corruption’” as described
in section 4301, subdivision (f).

                 ii.   Delayed Billing
     The trial court also addressed IVS/Vara’s contention that the
evidence did not support the Board’s finding that IVS intentionally
delayed sending most of its bills to J.M.’s insurer until after J.M. had
completed his treatment. The court acknowledged the evidence IVS had

                                     38
presented that billing can be delayed by “the administrative burden of
doing claims processing,” and that providers generally get a better
response when they wait until the end of service and submit a single
claim instead of submitting multiple claims throughout the treatment
period. But the court found that Vara’s explanation about how IVS
billed patients’ insurers was not consistent with how IVS billed J.M. or
R.M. For example, Vara testified that IVS bills at regular intervals for
treatments that last for long periods of time, but that it waits until the
end of treatment to bill for treatments that last four to six weeks. Vara
also explained that IVS prefers to bill for the entire treatment at one
time so the insurer has the authorization for the entire course of
treatment and does not mistake multiple billings for duplicates. But
the court noted the evidence showed that, although IVS did not send the
first bill for R.M.’s treatment until near the end of the treatment, it sent
multiple bills on several different days rather than a single bill at the
end of treatment. And with regard to J.M., the evidence showed that
IVS sent bills to the insurance company after the first three months of
treatment (covering the first two months), but after J.M.’s wife
complained about charges, IVS did not send another bill to the insurer
for a year (sending the bill four months after J.M.’s treatments ended).
     Based upon this evidence, the court found the Board reasonably
concluded that IVS intentionally delayed submitting bills for J.M.’s
treatment to his insurer. Considering that intentional delay along with
IVS’s failure to disclose the cost of treatment and its out-of-network
status, the court found that the Board reasonably concluded that IVS

                                    39
delayed that billing “in a concerted effort to avoid providing J.M.’s wife
with information about its charges.”

           c.    Arguments on Appeal
     On appeal, IVS/Vara argue the Board abused its discretion by
basing its determination sustaining the first cause for discipline on
IVS’s billing practices because: (1) the Board did not have jurisdiction
to address billing issues; (2) the Board improperly based its decision on
IVS’s alleged failure to follow an internal policy IVS voluntarily
adopted; and (3) the Board improperly relied upon IVS’s delay in billing
J.M. in finding IVS was guilty of moral turpitude and deceit. We note
that in making these arguments, IVS/Vara completely ignore the trial
court’s rulings and the standards of review governing our review in this
case. We respond to each issue applying the appropriate standard of
review for that issue.

                 i.      Board’s Jurisdiction
     IVS/Vara contend, in essence, that the Board committed an error
of law by taking disciplinary action based upon billing issues. We
review this contention under the de novo standard of review, and find it
has no merit.
     There is no dispute that the Board does not have jurisdiction over
complaints regarding a pharmacy’s pricing of prescription drugs or
billing disputes with a patient’s insurance company. But it does not
follow that, as IVS/Vara appear to assert, this lack of jurisdiction to
address complaints about pricing or billing precludes the Board from

                                     40
considering any evidence related to the prices a pharmacy charged or
the timing of their billing when determining whether the pharmacy
engaged in unprofessional conduct as defined in section 4301,
subdivision (f).
      In this case, the Board did not discipline IVS for the prices it
charged or billing disputes with patients’ insurers. Rather, it
considered evidence of the extremely high prices IVS charged for J.M.’s
and R.M.’s treatments as evidence showing IVS’s motive for not
following its P&Ps that required it to disclose the costs of care to
patients before treatment starts. And it considered evidence of IVS’s
billing practices, particularly its extraordinary delay in submitting bills
to J.M.’s insurer after J.M.’s wife had complained about the prices
charged for the first two months of treatment, as evidence showing
IVS’s intent to prevent J.M. from discovering the amounts IVS was
charging until after the treatment ended. In other words, the Board
considered the evidence of IVS’s pricing and billing practices not to
determine whether the pricing and billing practices themselves violated
any statutes, rules, or regulations. Instead, that evidence went to
whether IVS intended to deceive J.M. and R.M., and its motive for that
deception. The Board did not err by considering it in that context.

                   ii.   Failure to Follow Internal Policy
      IVS/Vara contend (1) it was improper for the Board to base its
finding of unprofessional conduct on IVS’s failure to follow its own
internal policies because a finding of moral turpitude must be based
upon a wrongdoing that involves a violation of a clearly defined law or

                                     41
regulation, and cannot be premised on the failure to follow a term of
accreditation by a private entity; and (2) the weight of the evidence does
not support the Board’s finding that IVS failed to follow its policies.
     The first contention presents an issue of law, which we review de
novo. We find no merit to the contention.
     First, in arguing that a finding of “unprofessional conduct” under
section 4301, subdivision (f) must be based upon a violation of a clearly
defined law or regulation, IVS/Vara focus only on cases in which the
“unprofessional conduct” findings were based upon acts involving moral
turpitude. But section 4301, subdivision (f), is not limited to such acts.
That subdivision also defines “unprofessional conduct” to include acts
involving “dishonesty, fraud, deceit, or corruption.” (§ 4301, subd. (f).)
     Second, there is nothing in the language of section 4301,
subdivision (f), indicating that the act at issue must involve the
violation of a statute or regulation. Indeed, it expressly provides that
the act need not be a felony or misdemeanor.
     Finally, as the trial court’s ruling makes clear, the act in this case
that constituted “unprofessional conduct” was not simply IVS’s failure
to follow its P&Ps. Instead, it was IVS’s conduct in adopting a policy in
order to obtain the accreditation it was required to have to do sterile
compounding and that gave it significant business advantages, but
then, once it obtained that accreditation, adopting a different policy
that was contrary to the original policy. As the trial court stated, this
conduct clearly “falls within the broad range of ‘act[s] involving moral
turpitude, dishonesty, fraud, deceit, or corruption’” that constitute
“unprofessional conduct” under section 4301, subdivision (f). Thus,

                                     42
Board did not err in considering IVS’s failure to follow its P&Ps when it
found that IVS engaged in “unprofessional conduct.”
     As noted, IVS/Vara also challenge the finding of “unprofessional
conduct” on the ground that the weight of the evidence does not support
the Board’s finding that IVS violated its internal policies because the
Board ignored certain testimony by Casillas. In making this contention,
IVS/Vara ignore the applicable standard of review. Our task on review
is to determine whether there is substantial evidence to support the
trial court’s conclusion that the Board’s finding was supported by the
weight of the evidence. (Fukuda, supra, 20 Cal.4th at p. 823.)
IVS/Vara do not discuss the evidence the trial court relied upon at all.
In fact, they do not even discuss the evidence the Board relied upon;
instead, they discuss only the testimony they assert the Board
purportedly ignored.
     As we explained in Shenouda v. Veterinary Medical Bd. (2018) 27
Cal. App. 5th 500, “when the substantial evidence standard of review
applies, the appellant is required ‘“to demonstrate that there is no
substantial evidence to support the challenged findings.” . . . A
recitation of only [the appellant’s] evidence is not the “demonstration”
contemplated under the above rule. [Citation.] Accordingly, [when
appellants] contend [that] “some particular issue of fact is not
sustained, they are required to set forth in their brief all the material
evidence on the point and not merely their own evidence. Unless this is
done the error assigned is deemed to be waived.”’” (Id. at p. 514.)
Because IVS/Vara have not addressed the trial court’s conclusion that

                                    43
the weight of the evidence supports the Board’s finding, or the evidence
relied upon by the trial court in reaching this conclusion, they have
forfeited their claim.

                 iii.    Delay in Billing
     IVS/Vara contend the weight of the evidence does not support the
Board’s determination that IVS committed an act of moral turpitude or
deceit by delaying its billing with regard to J.M. To make this
argument, they question the credibility of the Board’s expert witness,
and question the Board’s reliance upon the testimony of one witness
(Vara) over the testimony of another (Casillas). Not only do IVS/Vara
again ignore that our review is of the trial court’s determination, the
questions they raise are questions that cannot be considered under the
standard of review applicable here.
     As noted, it is the trial court that determines if the weight of the
evidence supports the Board’s findings. On appeal, we do not weigh the
evidence, and instead review the trial court’s finding under the
substantial evidence standard of review. (Fukuda, supra, 20 Cal.4th at
p. 823.) Under that standard of review, “‘“‘the power of an appellate
court begins and ends with the determination as to whether, on the
entire record, there is substantial evidence, contradicted or
uncontradicted, which will support the [trial court’s] determination, and
when two or more inferences can reasonably be deduced from the facts,
a reviewing court is without power to substitute its deductions for those
of the trial court. If such substantial evidence be found, it is of no
consequence that the trial court believing other evidence, or drawing

                                     44
other reasonable inferences, might have reached a contrary
conclusion.’”’” (Perez v. VAS S.p.A. (2010) 188 Cal. App. 4th 658, 683-
684.) Moreover, “we do not evaluate the credibility of the witnesses. . . .
Rather, ‘we defer to the trier of fact on issues of credibility.’” (Escamilla
v. Department of Corrections & Rehabilitation (2006) 141 Cal. App. 4th
498, 514-515.)
     In this case the trial court acknowledged the evidence IVS/Vara
presented that IVS did not intentionally delay in submitting its bills for
J.M.’s treatment. But the court cited to evidence showing
inconsistencies between how Vara testified IVS billed patients’ insurers
(Vara testified that for four-to-six-week treatments IVS waits until the
end of treatment to submit everything at the same time, but it submits
at regular intervals for longer treatments) and how IVS actually billed
the insurers for J.M. and R.M. (IVS submitted multiple bills on several
days for R.M.’s treatment, and submitted one bill after the first two
months of J.M.’s 10-month treatment but did not submit any other bill
until four months after the treatment ended. ). Thus, substantial
evidence supported the court’s finding that the Board reasonably
inferred, based upon those inconsistencies, that IVS’s delay in
submitting J.M.’s bills was intentional.

     3.    Third and Fourth Causes for Discipline
     The third and fourth causes for discipline alleged violations of
California Code of Regulations, title 16, section 1793.1 (Regulation
1793.1) based upon Vara’s conduct in responding to calls from the
family of D.K. regarding problems they were having with the

                                     45
prescription Curlin pump that IVS had provided. Regulation 1793.1
sets out duties that only a pharmacist, or an intern pharmacist acting
under the supervision of a pharmacist may perform. Those duties
include: “Consult with a patient or his or her agent regarding a
prescription, either prior to or after dispensing” (Reg. 1793.1, subd. (b));
“Consult with any prescriber, nurse or other health care professional or
authorized agent thereof” (Reg. 1793.1, subd. (e)); and “Perform all
functions which require professional judgment” (Reg. 1793.1, subd. (g)).
     The third cause for discipline alleged that Vara violated
subdivisions (b) and (e) of Regulation 1793.1, and the fourth cause for
discipline alleged that Vara violated subdivision (g). Because the facts
and argument regarding both causes are the same, we will discuss both
causes together.

           a.      The Board’s Findings and Conclusions
     The Board found that Vara responded to calls made to IVS by
members of patient D.K.’s family (Kevin and Donna) about the Curlin
pump, which the family members believed had malfunctioned and
administered an improper dose of medication to D.K. overnight. The
Board found that after being notified of the family’s calls and learning
that PIC Sadow was on vacation, Vara decided to handle the matter
himself. When both Kevin and Donna asked, in separate calls, that the
pump be replaced, Vara made the decision to deny their requests. And
when Donna asked to speak with a pharmacist, Vara told her that he
was the person she should speak to.

                                     46
     The Board found that any decision regarding the equipment
involved in dispensing prescribed medication was a decision that must
be made by a licensed pharmacist. It noted that, although Vara had
every right to take the initial calls from the family and decide where to
direct them, by making the decision by himself—without the
involvement of a licensed pharmacist—that the pump was not
malfunctioning and did not need to be replaced, he improperly
consulted with a patient’s family concerning a prescription.
     Based upon these findings, the Board concluded that Vara
violated Regulation 1793.1, subdivisions (b) and (g).18

           b.    The Trial Court’s Ruling
     The trial court found the evidence established that Kevin and
Donna spoke with Vara several times on the day in question, asking to
speak to a pharmacist and that the pump be replaced, and that Vara
refused to replace the pump or direct their calls to a pharmacist. The
court also noted there was no admitted evidence that Vara ever
consulted with a licensed pharmacist to determine whether the pump
was functioning properly. Instead, the court found the evidence showed
that the only time Vara spoke to a pharmacist that day was when
Sadow spoke to him early that morning, and that she only confirmed
with him that she was on vacation and that he needed to call the
pharmacist on call, Jeannie Kim. The court also noted there was

18   The Board concluded it was not established that Vara violated
Regulation 1793.1, subdivision (e).

                                    47
evidence that, because a Curlin pump is classified as a “dangerous
device,” a licensed pharmacist must make the judgment call about
whether a pump is working properly or should be replaced.
      Based upon this evidence, the court concluded that the weight of
the evidence supported the Board’s determination that Vara performed
the duties of a licensed pharmacist in violation of Regulation 1793.1,
subdivisions (b) and (g).

            c.    Argument on Appeal
      IVS/Vara contend the weight of the evidence does not support the
Board’s finding the Vara performed the duties of pharmacist. Once
again, IVS/Vara ignore our role on review and the limits of the
substantial evidence standard of review.19
      IVS/Vara’s argument is based primarily upon their assertions of
conflicts in the evidence and lack of credibility of the Board’s witnesses.
When those assertions are removed, what is left is IVS/Vara’s
admission that “all that was established” was that Vara received the
phone calls from D.K.’s family complaining about the pump and asking
for it to be replaced, and that Vara declined to replace the pump and

19     We note that IVS/Vara spend a significant portion of their argument
citing to evidence to show that “D.K.’s family members’ conversations with
two nurses [on the dates the pump seemed to be malfunctioning] . . . fulfilled
any pharmacist consult requirement that existed.” But the third and fourth
causes for discipline did not allege that IVS failed to have consultation
available with regard to D.K.; the only cause for discipline related to IVS’s
failure to have consultation available was the twelfth cause for discipline,
which was based upon the incident involving patient C.R.

                                      48
instead sent a nurse to reprogram it after speaking with the pump’s
manufacturer.20 But those facts constitute substantial evidence
sufficient to support the trial court’s finding that the weight of the
evidence supports the Board’s conclusion that Vara violated Regulation
1793.1, subdivisions (b) and (g).

      4.    Sixth Cause for Discipline
      The sixth cause for discipline alleged that on at least two
occasions, prescription labels were used that falsely represented the
name of the pharmacy as “IV Solutions Clinical Pharmacy,” an
unknown, unlicensed pharmacy, instead of “IV Solutions, Inc.,” the
name on the license issued by the Board. Therefore, IVS and PIC
Sadow are subject to disciplinary action for unprofessional conduct
under section 4301, subdivisions (f), (j), (o), and (p) for violating section
4078, subdivision (a)(1), and section 4076, subdivision (a)(6).
      Section 4078, subdivision (a)(1) provides: “No person shall place a
false or misleading label on a prescription.” Section 4076, subdivision
(a)(6) provides: “A pharmacist shall not dispense any prescription
except in a container that meets the requirements of state and federal
law and is correctly labeled with all of the following: [¶] . . . [¶]

20    IVS/Vara also assert the evidence showed that Vara spoke with IVS’s
pharmacist. But the trial court found that he spoke only to Sadow, that
Sadow only told him that she was on vacation and that he needed to speak to
Jeannie Kim, and that Vara never spoke to Kim that day. Substantial
evidence supports this finding.

                                      49
(6) The name and address of the pharmacy, and prescription number or
other means of identifying the prescription.”

           a.    Board’s Findings
     The Board found that on April 2 and 7, 2010, PIC Sadow used
prescription labels that represented the name of the pharmacy as “IV
Solutions Clinical Pharmacy” instead of “IV Solutions, Inc.” It found
that Sadow did not make the decision to use that name, but instead
“simply went along with the practice.” It also found there was no
evidence of any intent to deceive the public, but rather the intent was
“to denote that this was a closed, clinical pharmacy that mixed its own
IV solutions and medications.” The Board noted that Casillas and
Sadow were surprised to learn that use of that name was improper, and
immediately stopped using it.
     The Board concluded that IVS is subject to disciplinary action for
unprofessional conduct under section 4301, subdivisions (f), (j), (o), and
(p) for violating section 4078, subdivision (a)(1), and section 4076,
subdivision (a)(6).

           b.    Trial Court’s Ruling
     In the trial court, IVS/Vara challenged the Board’s ruling on the
sixth cause for discipline on a single ground: they argued that the
Board erred in concluding their use of the name “IV Solutions Clinical
Pharmacy” constituted “unprofessional conduct” under section 4301,
subdivision (f), because the Board found that the name was not used
with the intent to deceive the public. The trial court rejected their

                                    50
argument, finding that doing business under an unlicensed name in
violation of section 4078, subdivision (a)(1)—the same conduct for which
IVS previously had been cited for using the name “Stat Clinical
Pharmacy”—“falls within the broad range of dishonest, fraudulent, and
deceitful conduct for which the Board is authorized to take action under
Section 4301(f).” The court also noted that, in any event, violation of
section 4078, subdivision (a)(1), was independently actionable under the
other subdivisions of section 4301 cited by the Board: subdivision (j)
(“The violation of any of the statutes of this state”); subdivision (o)
(“Violating . . . any provision or term of [the Pharmacy Law]”); and
subdivision (p) (“Actions or conduct that would have warranted denial
of a license”).

            c.    Argument on Appeal
      IVS/Vara begin their argument here with a misstatement of the
record. They state: “On the 6th cause, the Board found that IVS’ use of
the name ‘IV Solutions Clinical Pharmacy,’ instead of ‘IV Solutions, Inc.’
on a few prescription labels constituted acts of moral turpitude and
deceit.” They then argue this was error because the Board found there
was no evidence IVS intended to deceive the public by using the
different name.
      There are two problems with IVS/Vara’s argument. First, the
Board did not find that IVS’s use of the name constituted acts of moral
turpitude and deceit. Rather, it found that the use of the name fell
within the broad range of conduct described in section 4301, subdivision
(f)—i.e., “act[s] involving moral turpitude, dishonesty, fraud, deceit, or

                                     51
corruption.” (Italics added.) Thus, as the trial court found, the Board
reasonably could have found that IVS’s use of the name was dishonest,
particularly in light of the fact that IVS previously had been cited for
using another unlicensed name.
      Second, the Board found that IVS’s use of the name constituted
“unprofessional conduct” under other subdivisions of section 4301, in
addition to subdivision (f), and the trial court found the weight of the
evidence supported those findings. IVS/Vara do not challenge the trial
court’s ruling or those findings. Because IVS/Vara failed to do so, they
have forfeited their challenge to the sixth cause for discipline. (Lafferty
v. Wells Fargo Bank (2013) 213 Cal. App. 4th 545, 571-572 [on appeal,
trial court’s ruling are presumed correct; where ruling was based upon
multiple grounds and appellant addresses only one ground, appellant’s
challenge to ruling is forfeited].)

      5.    Punishment
      IVS/Vara contend the Board abused its discretion by imposing
revocation as the penalty for the sustained causes for discipline. They
argue the Board incorrectly applied the Guidelines and improperly
relied upon IVS’s pricing in choosing revocation. They also argue that
revocation was inappropriate because only 12 of the 21 alleged causes
for discipline were sustained, and most of the sustained violations were
unintentional. We disagree.

                                      52
           a.    Incorrect Application of the Guidelines
     As noted, the Guidelines set forth four categories of violations for
which the Board may take disciplinary action. For each category, the
Guidelines list “statutes and regulations where violations would
typically merit the recommended range of minimum to maximum
penalties for that category.” (Guidelines, p. 5.) The Guidelines instruct:
“These categories assume a single violation of each listed statute or
regulation. For multiple violations, the appropriate penalty shall
increase accordingly. Moreover, if an individual has committed
violations in more than one category, the minimum and maximum
penalties shall be those recommended in the highest category.” (Id.)
     The Guidelines also list 15 factors to be considered by the Board in
determining penalties, with the following guidance: “No single one or
combination of the [listed] factors is required to justify the minimum
and/or maximum penalty in a given case, as opposed to an intermediate
one.” (Guidelines, p. 3.) The listed factors, some of which are not
applicable to this case, are: (1) actual or potential harm to the public;
(2) actual or potential harm to any consumer; (3) prior disciplinary
record; (4) prior warnings, including citations and fines; (5) number
and/or variety of current violations; (6) nature and severity of the acts
or offenses under consideration; (7) aggravating evidence; (8) mitigating
evidence; (9) rehabilitation evidence; (10) compliance with terms of any
criminal sentence, parole, or probation (not applicable here); (11) overall
criminal record (not applicable here); (12) evidence of proceedings for
case being set aside and dismissed under Penal Code section 1203.4 (not
applicable here); (13) time passed since the acts or offenses;

                                    53
(14) whether the conduct was intentional or negligent or demonstrated
incompetence; and (15) financial benefit to the respondent from the
misconduct. (Guidelines, p. 3.)

                  i.     Mischaracterizing Violations
      IVS/Vara argue that the Board improperly characterized the first,
sixth, and seventh causes of discipline as Category II, Category II/III,
and Category III, respectively,21 when all three should have been
characterized as Category I violations, and that, in imposing revocation,
the Board improperly treated all violations as having been Category III.
They are mistaken.
      With regard to the first cause for discipline (failure to disclose
information to patients J.M. and R.M.), IVS/Vara argue that the
conduct at issue was, at most, a violation of section 4122, subdivision
(b), which requires pharmacies to provide, upon request, the current
retail price for any drug sold at the pharmacy; under the Guidelines, a
violation of section 4122 is a Category I violation. But the Board did
not find that the conduct was a violation of section 4122. It found that
the conduct constituted “unprofessional conduct” under section 4301,
subdivision (f). The trial court found the weight of the evidence
supported the Board’s conclusion that the conduct fell within section
4301, subdivision (f), and we found that substantial evidence supports

21    We note that the trial court found that the Board erred in
characterizing the sixth cause for discipline as Category II/III, finding it was
a Category II violation.

                                       54
the trial court’s finding. The Guidelines do not list section 4301,
subdivision (f) under Category I; it is listed as a Category II violation.
(Guidelines, pp. 6-11, 13.) Thus, the Board did not abuse its discretion
by characterizing the first cause for discipline as a Category II violation.
     IVS/Vara contend the sixth cause for discipline (false and
misleading label on a prescription) could not be considered a Category II
or Category III violation because the Board found that IVS’s use of the
false pharmacy name was a violation of section 4078, subdivision (a)(1),
which is listed in the Guidelines as a Category I violation. This
argument is disingenuous. The sixth cause for discipline alleged and
sustained a violation of both section 4078, subdivision (a)(1), and section
4076, subdivision (a)(6). While IVS/Vara are correct that a violation of
section 4076 is listed in the Guidelines as a Category I violation, a
violation of section 4078 is listed as a Category II violation.
(Guidelines, pp. 6, 12.) Therefore, as the trial court found, the sixth
cause for discipline properly was characterized as a Category II
violation.
     IVS/Vara’s argument regarding the seventh cause for discipline
does not address at all the statute the Board found IVS violated.
Instead, they argue the violation should not have been characterized as
a Category III violation because it involved “a minor record keeping
error” and appeared to be inadvertent. However, the statute the Board
found IVS had violated—section 4081, subdivisions (a) and (b)—is listed
under Category III, not Category I. (Guidelines, p. 16.) Had the
seventh cause for discipline been the only cause that was sustained,
IVS/Vara’s argument might have been an appropriate argument for the

                                     55
minimum penalty allowed. But in light of the statute found to have
been violated, the Board did not abuse its discretion by characterizing
the seventh cause as a Category III violation.
     Nor did the Board abuse its discretion by concluding it should
“treat[] the totality of the violations to be in the highest category, here
Category III,” as IVS/Vara argue. IVS/Vara acknowledge that the
Guidelines instruct that the range of penalties to be applied when there
are violations in more than one category is the range applicable to the
highest category in which any of the violations is found. But they argue
this does not mean that the Board was required to treat all of the
violations as equally severe as the most severe violation when
determining the penalty, as it contends the Board did in this case. We
disagree with that contention.
     Viewed in context, it is clear that in stating that it would “treat[]
the totality of the violations to be in the highest category,” the Board
was referring to the range of penalties applicable to all of the violations
rather than the severity of the violations. Immediately following the
statement, the Board stated: “Such treatment appears warranted given
the fact that the bulk of violations are in or near Category III.
Moreover, the difference between the two categories [i.e., Category II
and III] is without significant distinction. The suggested discipline for
both categories ranges from a minimum of probation for a number of
years under various terms and conditions to a maximum of revocation.”
In other words, the focus of the Board was on the range of penalties it
was to consider in light of the 15 factors as applied to all of the
violations as a whole. The Board then turned to and applied the

                                     56
factors, taking into account, as the Guidelines instruct, that “[f]or
multiple violations, the appropriate penalty shall increase accordingly.”
(Guidelines, p. 5.) The Board did not abuse its discretion in doing so.

                 ii.   Failure to Consider/Misapplication of Factors
     IVS/Vara contend the Board misapplied “a number” of the 15
factors to be considered in determining the appropriate penalty under
the Guidelines. However, in their discussion they identify only two—
the second and the ninth factors (actual or potential harm to any
consumer, and evidence of rehabilitation, respectively). We find no
abuse of discretion in how the Board applied those factors.

                       A.    Actual or Potential Harm to Consumers
     The Board found that actual or potential harm to consumers was
demonstrated in four instances: (1) Dr. Spitzer, a physician who
referred his patients to “Stat Clinical Pharmacy,” was defrauded
because IVS used that name to avoid detection after Dr. Spitzer refused
to refer his patients to IVS (fourteenth cause for discipline); (2) patient
D.K. received only two weeks of his six-week regimen of IV antibiotics
due to the confusion over whether the Curlin pump malfunctioned
(third and fourth causes for discipline); (3) patient C.R. was unable to
receive her prescribed IV morphine for her post-surgery pain because
IVS was unavailable for consultation regarding the Curlin pump
(twelfth cause for discipline); and (4) patients J.M. and R.M. suffered
significant harm because at the time of the incidents, both had lifetime
insurance benefit caps that were exhausted (J.M.) or significantly

                                     57
depleted (R.M.) due to IVS charging multiple-times more for their
treatments than in-network pharmacies would have charged, and J.M.
was additionally harmed because IVS filed a lawsuit seeking more than
$2 million against him and his wife (first cause for discipline).
     IVS/Vara contend the Board misapplied this factor, because three
of the four instances the Board identified do not, in fact, demonstrate
harm to a consumer. We disagree.
     First, IVS/Vara contend the Board’s finding that Dr. Spitzer was
defrauded does not demonstrate harm to a consumer because “as a
matter of law Dr. Spitzer was not a consumer and therefore under the
Guidelines, harm that he suffered was not relevant to this factor.”
IVS/Vara do not cite to any law in support of their assertion that Dr.
Spitzer was not a consumer as a matter of law. In fact, the term
“consumer” is not defined in the Pharmacy Law. It is not unreasonable
to conclude, as the Board apparently did, that a consumer of specialized
pharmacy services such as the services IVS offered includes not just the
patient, but also the physician who refers the patient to a specific
pharmacy, especially when he does so to avoid using a particular
pharmacy.
     Second, IVS/Vara argue that D.K. was not harmed by Vara’s
conduct with regard to the Curlin pump because D.K.’s family elected to
take D.K. off of the pump, and D.K. completed his regimen with oral
medications. But IVS/Vara ignore the fact that D.K.’s doctor had
prescribed an IV treatment rather than oral medication and that D.K.’s
family took D.K. off of the pump because of their interactions with Vara,

                                    58
during which he cursed at them and refused to replace the pump or let
them talk to a pharmacist.22
     Third, IVS/Vara argue that “[t]he alleged ‘significant harm’ to
J.M. and R.M. . . . is a fabrication of the Board” because J.M.’s and
R.M.’s insurers paid for their treatments, and because IVS’s lawsuit
against J.M. did not cost J.M. anything since his attorney fees were
paid by the insurance proceeds. In making this argument, IVS/Vara
completely ignore the harm the Board identified in its decision.
     To be fair, the Board did not specifically identify the “significant
harm” J.M. and R.M. suffered in its discussion of the second factor,
instead stating: “As chronicled in detail above, patients J.M. and R.M.
sustained significant harm.” But the Board’s decision included an
entire section—with the heading “Damages”—in its findings of fact with
respect to J.M. and R.M., showing the “significant harm” they suffered
as a result of IVS’s failure to disclose the costs of treatment.
     In short, the Board did not abuse its discretion in applying the
second factor when determining the appropriate penalty to impose.

22    We note that, even though IVS eventually resolved the problem with
the pump, it took almost 24 hours. D.K’s family started having trouble with
the pump the evening before they spoke to Vara, when the alarm would not
stop going off. IVS was called before 5:00 a.m. the following morning,
because D.K.’s family thought the pump had administered all of the
medication at once. It was not until 6:00 p.m. that evening that Vara sent a
nurse to D.K.’s home to fix the pump. Thus, D.K. was unable to get his IV
medications for the entire day.

                                     59
                        B.   Rehabilitation
     In addressing the ninth factor, evidence of rehabilitation, the
Board stated: “[IVS/Vara] essentially provided none. No evidence was
presented at the hearing indicating that [IVS/Vara] are now doing
things differently in light of this case. In fact, Mr. Vara accepted very
little responsibility for his misconduct. Instead, in their pre-trial
motions and closing briefs, Mr. Vara and IV Solutions have accused the
Board of wrongdoing.”
     IVS/Vara contend that in reaching this conclusion, the Board
ignored uncontradicted evidence of IVS/Vara’s rehabilitation and its
own findings, citing several examples. We have examined every one of
their citations and find that almost none of that evidence demonstrates
rehabilitation with respect to the violations found by the Board.
     For example, IVS/Vara cite to evidence or findings that IVS had
no prior record of discipline and, when IVS received citations in the
past, it paid the fines without appeal and addressed the issues
immediately. IVS/Vara also cite to evidence that they always
cooperated with the Board’s investigations. While this evidence might
be evidence of other factors (such as mitigation), it is not evidence of
rehabilitation with respect to the violations in this case.
     IVS/Vara also cite to testimony by Vara and Casillas that IVS
always took corrective actions and took steps necessary to prevent
future “mistakes.” But the testimony they cite is entirely general; they
do not cite to evidence of specific steps taken to prevent future

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occurrences of most of the violations at issue.23 Moreover, the Board
had reason to doubt the veracity of Vara’s and Casillas testimony that
IVS had, in fact, corrected their “mistakes.” For example, although IVS
provided a statement to the Board that upon receiving the citation for
receiving and holding misbranded drugs (Lovenox) from Canada it
immediately shipped the medication back to the supplier, a Board
inspector later found several misbranded vials of Lovenox from Canada
at the pharmacy.
      In addition to the cited testimony, IVS/Vara point to “over a
hundred pages” of documentary evidence they contend reflects “IVS’
efforts to respond to and remediate the issues raised by the Board.”
Most of those pages do not pertain to the sustained violations in this
case. A few pages relate to the two violations for which we acknowledge
IVS presented evidence of rehabilitation, the second and seventeenth
causes for discipline. (See fn. 23, ante.) And while the remainder do
address some of the sustained violations, they do not show
rehabilitation—i.e., evidence that IVS implemented polices to prevent
future violations—for a variety of reasons.
      For example, several of the cited pages address the incident with
patient D.K. They include a narrative explaining in detail what Vara
purportedly did in responding to the calls from D.K.’s family. According

23    There are two exceptions. There is evidence that IVS immediately
stopped obtaining Curlin pumps from the unlicensed wholesaler and
researched to find a licensed one (second cause for discipline) and that it set
up a lock box for the key to the pharmacy and a system to ensure that only
the pharmacist can access it (seventeenth cause for discipline).

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to the narrative, Vara consulted with Sadow multiple times and worked
to resolve the issue with D.K.’s pump in consultation with the
pharmacist and the technical support person from the pump
manufacturer. Far from demonstrating rehabilitation, this evidence
demonstrates IVS/Vara’s refusal to recognize that any violation
occurred, in light of the Board’s finding that the evidence shows Vara
had only one call with a pharmacist, Sadow, who testified that she did
not “consult” with him but instead told him to speak to the pharmacist
on call.24
      Other pages of the cited evidence purport to show that IVS
immediately returned all of the misbranded Canadian Lovenox to the
supplier. But, as noted above, that was found to be untrue when an
inspector later found several vials of it at the pharmacy.
      Finally, some of the pages IVS/Vara cite to demonstrate a lack of
rehabilitation. IVS/Lara cite to IVS’s response to the citation it received
for using the name “Stat Clinical Pharmacy” on some of their
documents. IVS stated that it used that name for marketing purposes25
and was not aware that the use of that name violated any provisions of
the Pharmacy Law; it stated it would stop using the false name
immediately. Yet a year later, IVS was cited for using the false name

24    In any case, the Board expressly stated in its findings that it
disregarded most of the information in that narrative because it was not
contained in D.K.’s patient worksheet or chart.

25    In fact, as noted above, Vara and others admitted that IVS used the
name in order to receive referrals from Dr. Spitzer, who refused to refer
patients to IVS.

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“IV Solutions Clinical Pharmacy.” IVS responded to that citation by
stating that Vara was unaware that IVS could not use that name.
Clearly, IVS had not put policies in place to prevent future violations
after it was cited for using “Stat Clinical Pharmacy.”
     In short, while IVS/Vara may be correct that the record is not
entirely devoid of evidence of rehabilitation, that evidence is slight and
relates to only two of the 12 sustained violations. As a whole, the record
shows that IVS/Vara continue to deny wrongdoing and/or have not put
policies in place to prevent future violations as to most of the sustained
violations. As the Board observed, the facts and circumstances
regarding IVS’s violations “demonstrate such a pattern of willful
disregard for the laws pertaining to operating a pharmacy that [IVS]
should no longer be able to do so.” The Board did not abuse its
discretion in finding a lack of evidence of rehabilitation.

           b.    Improper Reliance on IVS’s Pricing
     Seizing on a single sentence in a lengthy paragraph summarizing
the reasons for its decision to impose revocation, IVS/Vara contend the
Board abused its discretion by relying in part on its pricing in
determining the level of discipline. In fact, the Board clearly states—in
that sentence—that while the prices IVS charged to J.M. and R.M. were
“unsavory,” they “were not illegal or the basis for discipline.” As the
remainder of the paragraph demonstrates, the Board’s revocation
decision was based upon several factors, which did not include IVS’s
pricing.

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           c.    Only 12 of 21 Causes for Discipline Were Sustained
     IVS/Vara contend that, because the Board initially sought
revocation based upon 21 causes for discipline but found that seven of
those 21 causes were not established,26 the Board abused its discretion
by imposing revocation based upon only 12 sustained causes. This is a
frivolous contention, without support in logic or law. The Board
properly made its penalty determination based upon the causes that
were sustained, not the causes that were alleged.

           d.    Most of the Violations Were Unintentional
     IVS/Vara argues that the Board improperly based its penalty
decision on its conclusion that “[m]ost of [the sustained] violations were
serious and intentional, the result of dishonesty, deceit or a conscious
decision by Mr. Vara to exclude pharmacists from their required
duties.” They contend that, in fact, most of the sustained violations (the
2nd, 3rd, 4th, 6th, 7th, 12th, 15th, 16th, 17th, and 21st causes for
discipline) “were found to be inadvertent or honest mistakes.” They are
wrong.
     Of the violations IVS/Vara identified, only two (the 7th and 12th
causes) truly could be found to have been inadvertent. The third and
fourth causes were the result of Vara’s conscious decision to exclude the
pharmacist on call from her required duty to respond to the concerns of
D.K.’s family about the prescription Curlin pump. The remaining
causes involve “mistakes” made because the person responsible for the

26   As noted, one of the causes for discipline was alleged only against PIC
Sadow and another was withdrawn.

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decisions leading to the violations—Vara, in most instances—was
unaware that the conduct violated the Pharmacy Law. In other words,
the violations resulted from Vara’s conscious decision not to pay
attention to the law governing his business, or as the Board put it, his
“willful disregard for the laws pertaining to operating a pharmacy.” .
Thus, the Board did not abuse its discretion in basing its penalty
decision on its determination that most of the violations were
intentional.

                            DISPOSITION
     The judgment is affirmed. The Board shall recover its costs on
appeal.
     NOT TO BE PUBLISHED IN THE OFFICIAL REPORTS

                                         WILLHITE, J.
     We concur:

     MANELLA, P. J.

     CURREY, J.

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