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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515002742
Report Date: 12/05/2023
Date Signed: 12/05/2023 01:36:37 PM


Document Has Been Signed on 12/05/2023 01:36 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: 3DATE:
12/05/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Rajveer Kaur and Manpreet DyalTIME COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analysts (LPA) Kerry Hiratsuka and Bethany Mirlohi, conducted this case management visit. LPAs reviewed staff and resident files.

LPA Hiratsuka also conducted a walk through.

LPA Mirlohi conducted a file review for 3 of 3 residents in care. LPA observed R1 and R2 had an outdated needs and service plan and it had not been updated yearly. In addition, LPA reviewed 3 of 3 resident medications comparing with resident's physician orders. LPA observed R1, R2, and R3 had medications orders however several medications were missing and unavailable to residents. LPA observed R3 had medication orders for glucose testing and insulin injections. Administrator stated caregiver performs the glucose testing and resident performs her own insulin injections. R3's LIC602, Physician's Report states resident is unable to perform glucose testing and insulin injections.

LPA Hiratsuka conducted a file review for four of four staff. One licensee is registered nurse and the other is a licensed vocation nurse. The training for the two remaining staff was done in November 2023 and is continuing.

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: 12/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 12/05/2023 01:36 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: 12/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/06/2023
Section Cited
CCR
87628(a)

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Diabetes. The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or
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By 12/06/2023, licensee shall submit in writing how they shall meet the needs of the resident and also how they shall screen residents in the future to ensure they can meet the needs.
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has it administered by an appropriately skilled professional. Based on record review and interview, the licensee did not comply with the section cited above because the resident is not capable and a caregiver who is not an appropriately skilled professional is doing it, which poses/posed an immediate risk to persons in care.
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Type A
12/06/2023
Section Cited
CCR87465(a)(4)

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Incidental Medical and Dental Care. A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall assist residents with
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By 12/06/2023, the licensee shall ensure all medications prescribed to the residents match the medications present in the facility and how they shall ensure this happens.
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self-administered medications as needed.
Based on record review, the licensee did not comply with the section cited above because the medication lists did not match the medications present in the facility 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: 12/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 12/05/2023 01:36 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: 12/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/22/2023
Section Cited
CCR
87463(c)

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Reappraisals. The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first...
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By 12/22/2023, the licensee shall come up with a written plan of correction how they shall ensure all reappraisals shall be done, meeting with resident and responsible party, and update the written plan of care.
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Based on record review, the licensee did not comply with the section cited above because two of three residents have them over 12 months 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: 12/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2023
LIC809 (FAS) - (06/04)
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