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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700766
Report Date: 11/07/2022
Date Signed: 11/07/2022 01:35:09 PM


Document Has Been Signed on 11/07/2022 01:35 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926



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: 3DATE:
11/07/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Ying Lui (Ruby) TIME COMPLETED:
02:00 PM
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 Licensing Program Analysts (LPAs) Talwinder Bains and Lavinia Muscan arrived at the facility unannounced on 11/07/2022 to conduct a case management to follow up on a recent incident about R1s missing incident and death report . LPAs met with facility administrator-Ying Lui (Ruby) and explained the purpose of the visit. LPAs ensured to apply hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn surgical masks. LPAs were screened upon entry by Ruby.

During today's visit, LPAs toured the facility and interviewed administrator-S1,1 staff-S2 and 3 residents (R2,R3 and R4) regarding R1s missing incident around 10/25/22 from facility and death report for R1 which facility reported to CCL on 11/01/22.

No deficiency issued during this visit.
Exit interview conducted and copy of the this report left at the facility.






SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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