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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 515002742
Report Date: 11/15/2023
Date Signed: 11/15/2023 02:48:40 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/31/2023 and conducted by Evaluator Kerry Hiratsuka
COMPLAINT CONTROL NUMBER: 59-AS-20230731122901
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
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Rajveer KaurTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Resident sustained severe pressure injury due to staff neglect.
Facility failed to seek medical attention.
Staff left resident in soiled diaper for extended period.
Staff unable to communicate with medical personnel.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Hiratsuka and Yang, conducted this visit to deliver the results of the allegations above that were investigated by Community Care Licensing Division (CCLD). The department conducted interviews, reviewed facility files, and reviewed resident medical records.

File review indicate the resident in question (R1) developed a pressure injury during a stay at the hospital and home health care was prescribed to heal the pressure injury. The facility did not provide the care required to heal the pressure injury resulting it starting at a stage two pressure injury from the hospital and led to it developing to an unstageable pressure wound while R1 was at the facility. Interviews revealed R1 is incontinent and required staff to assist changing the resident. Interviews conducted indicates Staff 1 (S1), who works overnight does not perform any incontinent care for the residents who are incontinent. S1 also stated they do not perform any activity of daily living care of the residents. R1 was not checked on during the overnight hours and not changed out of soiled diapers. Interviews also identified a second resident (R2) who stated they try not to urinate during the overnight hours because S1 does not change them.
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 59-AS-20230731122901
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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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R1 was also left in soiled diapers during the day. Staff stated R1 refused to be changed and the R1 stated that is not true. R1 stated they were not changed on a regular basis and R1 also stated R1 said “yes” to staff when staff asked R1 if they needed to be changed but was not changed. No written incontinent care plan was found in R1's file at the facility during a file review. Home health agency staff stated they found R1 in soiled diapers when they visited R1. Staff 2 (S2) also did not seek medical attention when the pressure injury on R1 worsened. S2 stated they were instructed to put cream on the pressure injury and to put a bandage on it if it fell off between the home health care agency checks. S2 stated they contacted the administrator and the responsible party when they noticed the pressure injury smelled bad and did not send R1 to the hospital until being instructed to do so by the responsible party. R1 was sent to the hospital 07/26/2023 and has not returned.

Title 22 regulations and California Health and Safety Code do not require staff to speak English. However, the regulations do require staff to be competent to provide services necessary to meet resident needs. LPA Hiratsuka was unable to communicate with two separate staff members. The first time was on 08/02/2023, and that staff member (S3) called S2 who showed up and LPA was able to communicate with S2. During the visit LPA met S1 and LPA was unable to communicate with S1 either. LPA found both S1 and S3 working by themselves. S2 stated they live a couple of minutes away and the others can call S2 at any time. Home health agency staff stated they were unable to communicate with S1 when they had questions and S1 had to call S2 and S2 arrived to finish the visits. S1 is also the overnight staff member. There is no proof S1 can call for emergency services by themself.

As a result of this investigation, the Department finds the allegations above to be Substantiated. A finding that the complaint is Substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. At the time of the complaint visit, an immediate civil penalty of $500 shall be assessed for a violation of California Code of Regulations Section 87463(a). The licensee was informed that a civil penalty was under review and may be assessed at a future date according to Health and Safety Code 1569.49.

Exit interview conducted. A copy of the report has been issued. Appeal Rights provided. signature on this report acknowledges receipt of the Appeal Rights
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
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 59-AS-20230731122901
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
87466
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Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.
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By 11/16/2023, the licensee shall submit a written plan of correction on they shall ensure staff will seek medical attention when required. $500 immediate civil penalties assessed
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This requirement is not met as evidenced by: Based on interviews and record reviews, the licensee did not comply with the section cited above because the staff did not seek medical attention and waited to be instructed to 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
CCR
87411(a)
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Personnel Requirements – General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs… This requirement is not met as evidenced by: Based on interviews and record reviews, the Licensee did not compy with the section
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By 11/16/2023, the licensee shall submit a written plan of correction on how they shall ensure staff are meeting the resident needs 24/7 and how they shall ensure a staff member is on duty at all times who can communicate with residents, home health care agency staff, and others.
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cited above because the staff did not seek medical attention and waited to be instructed, nor did the provide incontinent care to residents overnight, and cannot communicate with home health agency staff and CCLD staff 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
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 59-AS-20230731122901
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
87468.1(a)(2)
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Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by:
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By 11/16/2023, Licensee shall submit a written plan of correction on how they shall ensure staff meet the resident needs.
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Based on interviews, the licensee did not comply with the section cited above because S1 stated they do not change residents during the overnight shift out of soiled clothes and diapers 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
LIC9099 (FAS) - (06/04)
Page: 4 of 4