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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 515002742
Report Date: 12/12/2024
Date Signed: 12/12/2024 11:49:41 AM

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
10/22/2024 and conducted by Evaluator Kerry Hiratsuka
COMPLAINT CONTROL NUMBER: 59-AS-20241022143723
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:
12/12/2024
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Rajveer KaurTIME COMPLETED:
11:55 AM
ALLEGATION(S):
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Staff did not safeguard resident's personal belongings.
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, caregivers, and a witness were interviewed. LPA reviewed the file of the former resident in question.

Witness stated the belongings of a former resident were never returned. LPA reviewed the file and the former resident waived the inventory of their belongings when they moved in. Licensee and Administrator stated they have one large piece of furniture that belongs to the former resident and have not received any responses from the former resident in regards to what to do with the furniture. The caregiver interviewed stated she packed up all of the former resident's belongings into three boxes and someone came and picked up all three boxes. Witness stated the former resident has moved several times since the former resident left the facility.


Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
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 2
Control Number 59-AS-20241022143723
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: 12/12/2024
NARRATIVE
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Because the former resident waived the inventory of their belongings upon move in and never updated the list, moved several time since moving out of this facility, and interviews, LPA cannot prove or disprove the facility did not safeguard the former resident's belongings.

Due to the information gathered, LPA cannot determine the allegations: Staff did not safeguard resident's personal belongings. 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 OrdonezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2