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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515002742
Report Date: 02/15/2022
Date Signed: 02/15/2022 06:19:55 PM


Document Has Been Signed on 02/15/2022 06:19 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:YUBA SUTTER CARE HOME INC.FACILITY NUMBER:
515002742
ADMINISTRATOR:KAUR, RAJVEERFACILITY TYPE:
740
ADDRESS:920 BOGUE ROADTELEPHONE:
(530) 777-6476
CITY:YUBA CITYSTATE: CAZIP CODE:
95991
CAPACITY:6CENSUS: 5DATE:
02/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Babita Sharma, staffTIME COMPLETED:
06:25 PM
NARRATIVE
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On 2/15/2022, around 2:15pm, Licensing Program Analyst (LPA) Mai Thao arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Babita Sharma, care staff and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95.

Around 2:15pm, upon entry of the facility, LPA Thao and Care Staff observed the lock on the front door to be a dead bolt lock. LPA asked staff how is the door unlocked. Staff stated that a key is needed to unlock the front door. LPA and care staff confirmed that the door is locked and cannot be unlock without the keys. LPA Thao and care staff toured facility to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, three (3) bathrooms, four (4) bedrooms, kitchen, storage areas. Around 2:36pm, LPA Thao and staff toured the storage room next to the Great Room (common area). The storage room door was observed to be unlocked and opened. LPA and care staff observed 2 bed, and 2 shelves in the room. Care staff stated that the storage room is the staff room. LPA confirmed on facility sketch that this room was cleared by the Fire Marshal as a storage room, not a staff room. Around 2:41pm, LPA observed a drawer in the storage room with medications on top accessible to residents in care (Ferosul 325, Famotidine, Atorvastatin Calcium, Metformin HLC 500mg, Vitamin C + Zinc, Omeprazole 40mg, and other over the counter medications). Care staff stated that these medications belong to care staff's mother who stays in the room. Around 2:44pm, LPA and care staff observed 3 exits of the facility with no auditory devices (front entrance, sliding door in Great Room, and the left door next to the storage room in the Great Room). LPA and care staff observed 2 exits with auditory devices that were turned off and not on when care staff opened the door. Care staff stated that 5/5 residents in care have dementia. Around 3:10PM, LPA and care staff reviewed 5/5 resident files. LPA and Care staff observed 4/5 residents with a diagnosis of dementia. LPA and Care Staff observed 5/5 Needs and Services plan with dates from 2020. LPA and Care staff observed 3/5 residents with a diagnosis of dementia LIC 602 Physician's Report with dates from 2020.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted and appeal rights provided. A copy of this report was left at the facility.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Mai ThaoTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2022
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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Document Has Been Signed on 02/15/2022 06:19 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926


FACILITY NAME: YUBA SUTTER CARE HOME INC.
FACILITY NUMBER: 515002742

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/16/2022
Section Cited

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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night.. This requirement was not met as evidenced by:
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Based on observation and interviews, Licensee did not ensure that residents can leave the facility at anytime and not be locked in the building which poses an immediate health and safety and personal rights risks to all residents in care.
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Licensee agrees to review 87468.1 regulation and conduct training with staff by 2/23/2022. Licensee agrees to submit in proof of training topics and attendee signatures by 2/28/2022.
Type A
02/16/2022
Section Cited

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87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances...This requirement was not met as evidenced by:
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Based on observations and interviews, Licensee did not ensure medications were unaccessible to residents in care which poses an immediate health and safety and personal rights risk to all residents in care.
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Licensee agrees to conduct training with staff on 87705 and Licensee agrees to submit in proof of training topics and attendee signatures by 2/28/2022.
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: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Mai ThaoTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 02/15/2022 06:19 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926


FACILITY NAME: YUBA SUTTER CARE HOME INC.
FACILITY NUMBER: 515002742

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/22/2022
Section Cited

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87202 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.

This requirement was not met as evidenced by:
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Based on observations and interviews, Licensee did not ensure to obtain a fire clearance for the storage room to be a staff bedroom, which poses a potential health and safety and personal rights risks to residents in care.
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Type B
02/22/2022
Section Cited

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87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment...and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement was not met as evidenced by:
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Based on observations, Licensee did not ensure that 3/4 residents with dementia have an annual medical assessment and reappraisal done at least annually which poses a potential health and safety and personal right risks to residents in care.
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Licensee agrees to submit in copies of updated medical assessment and reappraisal by 3/15/2022.
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: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Mai ThaoTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 02/15/2022 06:19 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926


FACILITY NAME: YUBA SUTTER CARE HOME INC.
FACILITY NUMBER: 515002742

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/16/2022
Section Cited

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87705 Care of Persons with Dementia (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

This requirement was not met as evidenced by:
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Based on observations and interviews, Licensee did not ensure auditory devices were on exits and operational which poses an immediate health and safet and personal righs risk to residents in care.
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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: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Mai ThaoTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2022
LIC809 (FAS) - (06/04)
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