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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515002742
Report Date: 03/20/2024
Date Signed: 03/20/2024 02:22:23 PM


Document Has Been Signed on 03/20/2024 02:22 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:
03/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Manpreet DyalTIME COMPLETED:
02:30 PM
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On 3/20/2024, Licensing Program Analysts (LPAs) Cassie Yang and Kerry Hiratsuka arrived unannounced at the facility to conduct a required annual inspection utilizing the full care tool. LPAs met with caregiver, and explained the purpose of the visit. Licensee arrived to facility after tour was conducted.

This facility has a fire clearance for 6 non-ambulatory residents.

LPAs and Caregiver conducted a tour of the interior of the facility, areas toured included: residents bedrooms, bathroom, kitchen, garage and the common areas. LPAs observed kitchen to have sharps to be locked. LPAs observed facility to have ample food supply.

LPAs conducted a file review of four (4) residents files and nine (9) staff files. LPAs observed staff and residents file to be completed.

The following items were discussed:
-one of the resident rooms has a private shower and it appeared to be dark inside the shower when the shower curtain is closed even with the bathroom lights on. LPAs and Licensee discussed ways to brighten the inside of the shower
-the resident room with the shower has a smoke detector that gets set off when the resident opens the bathroom door after a shower due to the steam from the shower. Several suggestions were discussed to prevent the alarm from going off which includes installing a fan in the bathroom and moving the smoke detector to another part of the room.
-LPAs suggested installing window curtains for the bathrooms. The windows are frosted over for privacy but when the windows are open the windows do not provide privacy.

No deficiencies cited. Exit interview conducted.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2024
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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