515002742-1-30-2024-59-AS-KHOS-D27LTS-20240206080249

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 515002742
Report Date: 01/30/2024
Date Signed: 01/30/2024 02:23:25 PM

Unsubstantiated

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
12/06/2023 and conducted by Evaluator Kerry Hiratsuka

COMPLAINT CONTROL NUMBER: 59-AS-20231206135339

FACILITY NAME:	YUBA SUTTER CARE HOME INC.		FACILITY NUMBER:	515002742
ADMINISTRATOR:	KAUR, RAJVEER		FACILITY TYPE:	740
ADDRESS:	920 BOGUE ROAD		TELEPHONE:	(530) 777-6476
CITY:	YUBA CITY	STATE: CA	ZIP CODE:	95991
CAPACITY:	6	CENSUS: 3	DATE:	01/30/2024
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Rajveer Kaur and Manpreet Dyal		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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1. Facility staff ignored resident's calls for assistance.
2. Facility staff did not assist resident with using the restroom.
3. Facility staff left resident on the floor.

INVESTIGATION FINDINGS:

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LPA Hiratsuka conducted this visit to deliver the results of the investigation above. LPA met with

During the investigation the administrator, licensee, caregiver, and resident in question were interviewed. LPA also reviewed R1’s file

1. Resident (R1) stated staff do not answer calls for assistance. Administrator, Licensee, and Caregiver stated R1 has told them R1 is not receiving responses from agencies and companies R1 makes personal calls to. All three stated they answer R1's calls for assistance within five to ten minutes. LPA interviewed a second resident and the resident stated they receive assistance when requested. LPA cannot prove or disprove the allegation.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kerry Hiratsuka	TELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20231206135339

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: 01/30/2024

NARRATIVE

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2. R1 stated the staff do not help them to the bathroom. R1 stated R1 will have accidents because no one assists R1 to the bathroom. Licensee, Administrator and Caregiver stated R1 tells them R1 is unable to urinate but refuses to go to the hospital. They stated R1 would refuse assistance to the bathroom and R1 was able to use the bathroom by themselves. LPA did not observe any urine smell during an interview on 12/13/2023. LPA interviewed a second resident who stated they get assistance when requested.

3. R1 stated R1 was left on the floor for hours up to 24 hours several times and was only given a pillow and not assisted up and staff did not call emergency services to assist in getting up. Staff stated they responded within ten minutes to assist R1 up from the floor. Staff stated they did call twice to emergency services to pick up R1 up. Staff stated R1 refused to get up from the floor until the administrator and licensee arrived. LPA cannot prove or disprove because there were no other witnesses.

Due to the information gathered, LPA cannot determine the allegations: 1. Facility staff ignored resident's calls for assistance; 2. Facility staff did not assist resident with using the restroom; 3. Facility staff left resident on the floor. LPA finds allegation to be unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are unsubstantiated

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kerry Hiratsuka	TELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024

LIC9099 (FAS) - (06/04)

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