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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515002742
Report Date: 11/15/2023
Date Signed: 11/15/2023 02:53:51 PM


Document Has Been Signed on 11/15/2023 02:53 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: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:
11/15/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Rajveer KaurTIME COMPLETED:
03:00 PM
NARRATIVE
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While investigating Complaints 59-AS-20230731122901 and 59-AS-20230717132508, the following deficiencies were observed:

1. The facility staff (S1) that works overnight does not provide any incontinent care to the residents. S1 stated they do not check to see if a resident who requires assistance with incontinence care nor does S1 change the resident out of soiled clothes and briefs. Interviews show S1 does not respond to residents who request assistance during the overnight hours. The facility file does not have any staff training required by Title 22 regulations regarding night supervision. There is no proof S1 has first aid training and training to assist in caring for residents in the event of an emergency. California Health and Safety Code states the licensee may designate a qualified substitute in place of the administrator who has to be present on the premises 24 hours per day and that qualified substitute shall have qualifications adequate to be responsible and accountable for the management and administration of the facility. The staff member on duty overnight does not meet these requirements. There is no proof of any training to ensure the person is qualified.

2. A resident (R1) was on home health during the resident’s stay. The facility is required to have a copy of a written agreement of what the facility staff are to do and what the home health care agency is supposed to do. That was not found in the resident’s file.

3. The facility is required to have ongoing communication between themselves and the home health care agency. That was not found in R1’s file.

4. R1 developed a pressure injury during a hospital stay and was admitted with the pressure injury. The facility did not document R1 had a pressure injury. The licensee is required to do a preappraisal and a reappraisal when there is a change in condition. There is no documentation stating R1 had a pressure injury and what was being done about it.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2023
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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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: YUBA SUTTER CARE HOME INC.
FACILITY NUMBER: 515002742
VISIT DATE: 11/15/2023
NARRATIVE
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5. Prior to accepting a resident the licensee is required to do a functional capability assessment. There was no document in R1’s file stating it was done.

6. Title 22 regulations requires certain documentation to be in a resident’s file. A medical assessment is required to be in the resident’s file. S2 stated one was completed but was given to emergency personnel who took R1 to the hospital and it was not replaced. LPA was unable to review a medical assessment of the resident due to it not being in the file and not replaced.

7. Title 22 regulations requires a centrally stored medication log or list of medications the resident is prescribed to take. S2 stated she gave the list to the emergency personnel who took R1 to the hospital and did not replace it.

8. The administrator has demonstrated they do not have the knowledge to operate a facility based on the above issues that are being cited. The administrator also is being cited because a pressure injury that occurred at a hospital became worse while the resident was at the facility due to neglect of the staff. The staff did not change the resident out of soiled clothing and diapers. Licensee did not ensure staff who work the overnight shift check and change residents who require incontinent care. Licensee does not ensure there is a staff person working on each shift that is capable of communicating with home health agency staff, Community Care Licensing staff, and emergency personnel. S1 has to call another staff person when they are left alone for someone to come to the facility to communicate with others.

Deficiencies cited from Title 22 Regulations and or the California Health and Safety Code. Failure to correct shall result in civil penalties. appeal rights left
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/15/2023 02:53 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: YUBA SUTTER CARE HOME INC.
FACILITY NUMBER: 515002742

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/16/2023
Section Cited
HSC
1569.618(b)

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, Administration and management of residential care facilities; substituted qualifications; employee scheduling. At least one administrator, facility manager, or designated substitute who... has qualifications adequate to be responsible and accountable for the management and administration of the facility pursuant to Title 22 of the California Code of Regulations shall be on the premises 24 hours per day. The designated substitute may be a direct care staff member who shall not be required to meet the educational, certification, or training requirements of an administrator
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By 11/16/2023, Licensee shall submit a written plan of correction on how they shall ensure the staff working meet this health and safety code requirement
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This requirement is not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above because current staff did not/does not proof of required training which poses/posed an immediate health, safety or personal rights risk to persons in care.
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Type A
11/16/2023
Section Cited
CCR87415(a)

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Night Supervision The following persons providing night supervision from l0:00 p.m. to 6:00 a.m. shall be familiar with the facility's planned emergency procedures, shall be trained in first aid as required in Section 87465, Incidental Medical and Dental Care Services and shall be available as indicated
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By 11/16/2023, Licensee shall ensure staff working overnight have emergency procedure training and changing residents.
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below to assist in caring for residents in the event of an emergency. This requirement is not met as evidenced by: Based on record and interviews the licensee did comply with this section because S1 stated they do not change residents nor is there proof of emergency training which poses an immediate 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: Troy OrdonezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/15/2023 02:53 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: YUBA SUTTER CARE HOME INC.
FACILITY NUMBER: 515002742

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/01/2023
Section Cited
HSC
1569.725(a)(3)

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Incidental medical care; residential care facility. A residential care facility for the elderly may permit incidental medical services to be provided through a home health agency, licensed pursuant to Chapter 8 (commencing with Section 1725), when all of the following conditions are met:
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By 12/01/2023, the licensee shall submit a written plan of correction on how they shall ensure the resident's file has all the required paperwork when a resident uses a home health care agency.
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There is evidence of an agreed-upon protocol between the home health agency and the residential care facility for the elderly... Based on record review, the licensee did not comply with the section cited above because there was no written contract or paperwork between the resident and home health agency, which poses a potential, safety or personal rights risk to persons in care.
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Type B
12/01/2023
Section Cited
HSC1569.725(a)(4)

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Incidental medical care; residential care facility. A residential care facility for the elderly may permit incidental medical services to be provided through a home health agency, licensed pursuant to Chapter 8 (commencing with Section 1725), when all of the following conditions are met:
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By 12/01/2023, the licensee shall submit a written plan of correction on how they shall ensure the resident's file has all the required paperwork when a resident uses a home health care agency.
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There is ongoing communication between the home health agency and the residential care facility for the elderly about the services provided to the resident by the home health agency and the frequency and duration of care to be provided. Licensee did not comply because there were no records of communication between the facility and the home health care agency.
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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) 263-4700
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/15/2023 02:53 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: YUBA SUTTER CARE HOME INC.
FACILITY NUMBER: 515002742

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/01/2023
Section Cited
CCR
87505

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Documentation and Support Each facility shall document in writing the findings of the pre-admission appraisal and any reappraisal or assessment which was necessary in accordance with Sections 87457, Pre-admission Appraisal, and 87463, Reappraisals...
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By 12/01/2023, the licensee shall submit a written plan of correction on how they shall ensure the resident's file is complete
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Based on record review, the licensee did not comply with the section cited because there was no appraisal or reappriasal done on the resident indicating R1 had a wound which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
12/01/2023
Section Cited
CCR87459(a)

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Functional Capabilities The facility shall assess the person's need for personal assistance and care by determining his/her ability to perform specified activities of daily living. Such activities shall include, but not be limited-
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By 12/01/2023, the licensee shall submit a written plan of correction on how they shall ensure the resident's file is complete
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Based on record review, the licensee did not comply with the section cited because there was no functional capability conducted on any of the residents in care poses/posed a potential health, safety or personal rights risk to persons 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) 263-4700
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/15/2023 02:53 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: YUBA SUTTER CARE HOME INC.
FACILITY NUMBER: 515002742

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/16/2023
Section Cited
CCR
87625(b)(2)

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Managed Incontinence. In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night.
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By 11/16/2023, the licensee shall submit a written plan of correction and immediately ensure there are staff who work overnight check on residents and change them if need be.
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This requirement is not met as evidenced by: Based on interview, the licensee did not comply with the section cited above because S1 stated they do not change residents during the overnight shiff which poses/posed an immediate health, safety or personal rights risk to persons 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) 263-4700
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2023
LIC809 (FAS) - (06/04)
Page: 6 of 8


Document Has Been Signed on 11/15/2023 02:53 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: YUBA SUTTER CARE HOME INC.
FACILITY NUMBER: 515002742

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/01/2023
Section Cited
CCR
87506(b)(10)

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Resident Records. Each resident’s record shall contain at least the following information: Reports of the medical assessment specified in Section 87458, Medical Assessment, and of any special problems or precautions. This requirement is not met as evidenced by:
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By 12/01/2023, Licensee shall submit a written plan of correction on how they shall ensure resident files are complete.
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 Based on record review, the licensee did not comply with the section cited above because R1 went to the hospital and the medical assessment was sent with the resident and not replaced. which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
12/01/2023
Section Cited
CCR87506(14)

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Resident Records Each resident’s record shall contain at least the following information: Current centrally stored medications as specified in Section 87465, Incidental Medical and Dental Care Services. This requirement was not met as evidenced by:
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By 12/01/2023, Licensee shall submit a written plan of correction on how they shall ensure resident files are complete.
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 Based on record review, the licensee did not comply with the section cited above because R1 went to the hospital and the list of medications was sent with the resident and not replaced. which poses/posed a potential health, safety or personal rights risk to persons 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) 263-4700
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2023
LIC809 (FAS) - (06/04)
Page: 7 of 8


Document Has Been Signed on 11/15/2023 02:53 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: YUBA SUTTER CARE HOME INC.
FACILITY NUMBER: 515002742

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/01/2023
Section Cited
CCR
87405(h)(8)

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Administrator - Qualifications and Duties The administrator shall have the responsibility to: Have the personal characteristics, physical energy and competence to provide care and supervision and, where applicable, to work effectively with social agencies.
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By 12/01/2023, Licensee shall submit a written plan of correction on how they shall ensure the administrator is competent to operate the facility.
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 Based on record review, the licensee did not comply with the section cited above because staff don't have the required training, do not check residents who require incontinent assistance, employing staff who are qualified which poses/posed a potential health, safety or personal rights risk to persons 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) 263-4700
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2023
LIC809 (FAS) - (06/04)
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