342700766-8-28-2023-59-AS-TBAS-CV5VAY-20230828161643

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700766
Report Date: 08/28/2023
Date Signed: 08/28/2023 04:16:51 PM

Document Has Been Signed on 08/28/2023 04:16 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	YELLOWTAIL HOME CARE		FACILITY NUMBER:	342700766
ADMINISTRATOR:	LUI, YING		FACILITY TYPE:	740
ADDRESS:	8513 YELLOWTAIL WAY		TELEPHONE:	(916) 725-2445
CITY:	ANTELOPE	STATE: CA	ZIP CODE:	95843
CAPACITY:	6	CENSUS: 6	DATE:	08/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Administrator, Lui Ying (Ruby)		TIME COMPLETED:	04:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Talwinder Bains arrived on 08/28/23 to conduct the annual inspection. LPA met with administrator, Lui Ying (Ruby) and explained the purpose of today's visit. During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed resident (2) and staff files (2). All residents files have required paperwork. LPA observed incomplete paperwork for staff (S1,S2) files as mentioned in 809D. LPA and Administrator toured the facility together to ensure the health and safety of residents in care. The areas toured included resident rooms, bathrooms, kitchen, and common areas and outside area. The food supply is within compliance, 2 days of perishable and 7 days worth of non-perishable food items. Grab bars were present at the toilet and in the shower. All exits were unobstructed. There is a side gate for emergency access. LPA checked the kitchen area for the ability to prepare and store food. Knives and Sharp objects found to be locked. LPA observed the area used for medication to be locked and inaccessible to residents. LPA observed smoke detectors and carbon monoxide detector at the care home are operational. Hot water temperature was observed to be 112 degrees F, which is within the regulation range of 105-120 degree. LPA observed that staff left cabinet open by kitchen which contain disinfectants and cleaning supplies and were accessible to residents. LPA observed that facility has one (1) fire extinguisher which was last serviced in 2020. LPA requested a copy of the LIC 500, LIC610E and current liability insurance to be sent to the Department by 09/05/23.Deficiencies are cited on LIC809D per Title 22. Exit interview conducted. Appeal Rights and copy of this report left at facility.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder Bains	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023

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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Document Has Been Signed on 08/28/2023 04:16 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: YELLOWTAIL HOME CARE	FACILITY NUMBER: 342700766
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	LPA observed that facility's staff left cabinet open by the kitchen which has disinfectants, cleaning solutions which were accessible to residents and poses a immediate health and safety risks to residents in care.
	POC Due Date: 08/29/2023
	Plan of Correction
1 2 3 4	The Licensee will send the letter of understanding of this regulation and will train staff regarding this regulation and will send training documents to CCL. POC due date - 08/29/23.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder Bains	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/28/2023 04:16 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: YELLOWTAIL HOME CARE	FACILITY NUMBER: 342700766
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87202(a)

Fire Clearance

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs observations, facility has one fire extinguisher which was last serviced in 2020 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/05/2023
	Plan of Correction
1 2 3 4	The Licensee agrees to have the fire extinguisher serviced and will send a receipt and/or photograph of the fire extinguisher having been serviced. The receipt/photograph will be due by the POC due date - 09/05/23.

Type B

Section Cited

CCR

87412(a)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on Record Review for staff, S1,S2 files, LPA observed that S1 and S2 were missing- 1st Aid Certificate, LIC9052, TB test, LIC503 (for S1 only). Additionaly, S1 and S2 were fingerprint cleared but were Not Associated with facility which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/11/2023
	Plan of Correction
1 2 3 4	Licensee will complete all mentioned paperwork/documents for staff (S1,S2) files and will ensure that S1,S2 will be associated with facility and will send proof to CCL by POC date-09/11/23.

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: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder Bains	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023

LIC809 (FAS) - (06/04)

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