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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515002742
Report Date: 12/27/2023
Date Signed: 12/27/2023 03:13:57 PM


Document Has Been Signed on 12/27/2023 03:13 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: 4DATE:
12/27/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Manpreet Dyal and Rajveer KaurTIME COMPLETED:
03:15 PM
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A Non-Compliance conference was conducted today in the Sacramento Regional Office. The purpose of this meeting is to discuss the high volume of citations and a substantiated complaint. Present in the meeting is Regional Manager Alycia Berryman, Licensing Program Manager Laura Munoz, Licensing Program Analyst Kerry Hiratsuka, Licensing Program Analyst Bethany Mirlohi, and Licensee Manpreet Dyal and Administrator Rajveer Kaur, and Licensee Attorney Michael Benavides. The non-compliance conference process was explained during this meeting.

The facility has been cited 29 times in the last year. The facility was cited for the following issues. The facility was cited for 15 Type A citations, and 14 Type B citations.


Issues discussed during the meeting were:
• High volume of Type A citations
• Substantiated Complaint
• Staffing issues and training
• Communication Breakdown
• Administrators lack Oversight.
• Insufficient supplies for wound care and resources.
• caregivers not addressing residents care needs adequately.
• Facility failed to seek medical attention.
• Night Supervision
• Lack of Incontinence Care Plans
• Personal Rights
• Licensee/Administrator accountability
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE: 12/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2023
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: 12/27/2023
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The facility has stated they will do the following to achieve continued and substantial compliance:
• Increase the amount of training each staff
• Create policies and procedures to ensure compliance with staff training
• Who is responsible for staff and resident records and training

No deficiencies cited.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2