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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700766
Report Date: 10/05/2022
Date Signed: 10/05/2022 03:25:43 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/09/2022 and conducted by Evaluator Jacob Williams
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20220809075522
FACILITY NAME:YELLOWTAIL HOME CAREFACILITY NUMBER:
342700766
ADMINISTRATOR:LUI, YINGFACILITY TYPE:
740
ADDRESS:8513 YELLOWTAIL WAYTELEPHONE:
(916) 725-2445
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY:6CENSUS: 4DATE:
10/05/2022
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Ruby LuiTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff did not seek timely medical care for resident
Staff did not notify authorized representative of incident
Resident did not have sheets on the bed
Resident did not have a mattress pad on the bed
Staff are sleeping in the garage
Staff did not re-order resident's insulin needles timely
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jacob Williams arrived at the facility unannounced on 10/05/2022 to deliver findings of the complaint investigation for above allegations. LPA met with administrator Ruby Lui and explained the purpose of the visit. Prior to the visit , LPA completed required COVID-19 testing protocols and the daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA wore the following Personal Protective Equipment (PPE) during today's visit-surgical mask.

The department conducted records review, facility observations and interviews to investigate the complaint.


**Report continued on LIC9099-C**
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Jacob WilliamsTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/09/2022 and conducted by Evaluator Jacob Williams
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20220809075522

FACILITY NAME:YELLOWTAIL HOME CAREFACILITY NUMBER:
342700766
ADMINISTRATOR:LUI, YINGFACILITY TYPE:
740
ADDRESS:8513 YELLOWTAIL WAYTELEPHONE:
(916) 725-2445
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY:6CENSUS: 4DATE:
10/05/2022
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Ruby LuiTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff are not following physicians orders
INVESTIGATION FINDINGS:
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During the course of the investigation for the above allegation, the department conducted interviews. There were no documents available to review due to R1's file taken. Administrator admits to not giving R1 their prescribed suppositories throughout their time residing at Yellowtail. Although caregivers are not allowed to personally administer this medication, they failed to assist/guide R1 in self-adminsitering the medication.

Based on the evidence obtained, the preponderance of evidence standard has been met; therefore, the above mentioned allegation is found to be Substantiated. California Code of Regulations (Title 22) is being cited on the attached LIC 9099D. Appeal rights were provided, and the exit interview conducted.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alycia BerrymanTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Anthony PerezTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Citations on this Visit Report are Under Appeal!

Control Number 25-AS-20220809075522
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: YELLOWTAIL HOME CARE
FACILITY NUMBER: 342700766
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
10/12/2022
Section Cited
CCR
87465(a)(4)
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Incidental Medical and Dental Care (a) (4) The licensee shall assist residents with self-administered medications as needed.
This requirement was not met as evidenced by records and interviews that found R1 and R1 did not received medications as prescribed and orders by their physicians.
This posed an immediate health risk to residents.
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Licensee shall train all staff on medication adminstration. Licensee will provide a summary of training and attendance sheet of those who attended the training by the POC date of 10/12/2022.
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This requirement was not met as evidenced by interviews that found R1 did not receive medications as prescribed and orders by their physicians. This poses an immediate health risk to residents.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Jacob WilliamsTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 25-AS-20220809075522
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: YELLOWTAIL HOME CARE
FACILITY NUMBER: 342700766
VISIT DATE: 10/05/2022
NARRATIVE
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Allegation: Staff did not seek timely medical care for resident
Based on interview, administrator and care staff deny any claims from RP that R1 ever had a fall while residing at Yellowtail Home Care. There is no proof that a fall ever occurred nor an injury sustained, thus medical care was not required to be sought out.

Allegation: Staff did not notify authorized representative of incident
This allegation is referencing an alleged fall by the RP (previous allegation); based on interview, administrator and care staff deny any claims from RP that R1 ever had a fall while residing at Yellowtail Home Care. There is no proof that a fall ever occurred thus preponderance of evidence is not met and an incident or notifying authorized representatives was not required.

Allegation: Resident did not have sheets on the bed
Based on observation and interview, all beds in Yellowtail Home Care had sheets. There were no beds observed to not have mattress or sheets. Administrator states that if a bed did not have sheets at any point, it would've been because the sheets had been removed to be washed. All bedrooms were clean and contained all the necessary components on the occasions that LPA toured facility.

Allegation: Resident did not have a mattress pad on the bed
Based on observation and interview, all beds had sheets and the residents who needed a plastic covering had a plastic covering. There were no beds observed to not have mattress.

Allegation: Staff are sleeping in the garage
Based on observation and interview, the facility does not have a garage. In the front area of the facility are two rooms containing the staff room and staff office. The Administrator sleeps in the staff room, which is not a violation of Title 22 regulations.


**Report continued on LIC9099-C**
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Jacob WilliamsTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 25-AS-20220809075522
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: YELLOWTAIL HOME CARE
FACILITY NUMBER: 342700766
VISIT DATE: 10/05/2022
NARRATIVE
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Allegation: Staff did not re-order resident's insulin needles timely
R1 admits to stealing R1's resident file when arriving to move R1 out of the facility on 08/05/2022. Analyst made two attempts to obtain the file from RP's home but was unsuccessful both times. LPA asked RP to drop off file at Regional Office but RP refused. Thus the department was not able to view any medical information for R1, including information regarding R1's insulin needles. Through interview, Administrator and RP both state they were in communication and RP was planning on bringing new insulin needles to the facility for R1. These needles were never received due to RP moving R1 out. Administrator states R1 still had insulin needles remaining on the date R1 moved out, and that she gave the remaining insulin needles to RP on that night.

Based on interviews conducted by the Department, facility observations and records review, the preponderance of evidence standards has not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

No citations were issued today. Exit interview was conducted with Administrator and a copy of this report was provided via email. The signature of the Administrator on these forms acknowledges receipt of these documents.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Jacob WilliamsTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5