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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 11:43:51 AM

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
01/29/2024 and conducted by Evaluator Kerry Hiratsuka
COMPLAINT CONTROL NUMBER: 59-AS-20240129085315
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 seek medical attention for resident in care in a timely manner and
Staff did not report incident(s) involving resident as required.
Staff are not adequately trained.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kerry Hiratsuka, conducted this unannounced complaint visit to deliver the results of the allegations above.

The Department conducted an investigation into allegation that staff did not seek medical attention for resident in care in a timely manner and Staff did not report incident(s) involving R1 as required. On November 22, 2023, R1 was admitted to the hospital with a chief complaint of increased weakness over the past three days. Medical records indicated that R1 was diagnosed with possible aspiration pneumonia, failure to thrive, generalized weakness, and overall physical decline. Staff at the facility acknowledged observing R1’s increasing weakness and decreased mental alertness during this time. Additionally, staff reported that R1 required assistance with ambulation due to their weakened condition. However, these concerns were not escalated to licensed medical personnel.
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: 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 10
Control Number 59-AS-20240129085315
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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The investigation also determined that the facility failed to notify the Community Care Licensing Division of R1’s hospitalization, as required by regulations. As a result of these failures, R1’s medical care was delayed, leading to their hospitalization for conditions that could have been addressed sooner with timely intervention. R1 remained in the hospital until December 2, 2023, after which they were discharged to a skilled nursing facility. The facility has a meal log that documents the approximate amount of food eaten per meal. It shows a decline in the amount of food the resident was consuming three days prior to the resident being sent out to the hospital. Facility also did not report to Community Care Licensing Division that the resident was sent to the hospital due to decline. Based on interviews conducted and records reviewed, the preponderance of evidence standards have been met that the facility failed to seek timely medical care, notify the physician, and the Department that resident’s health was in decline. Therefore, the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D page. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) deficiency and civil penalty are being issued

An immediate civil penalty in the amount of $500.00 is to be assessed for a resident sustaining a serious bodily injury while in care at this facility. As a result of resident’s injury, the violation warrants a civil penalty assessment based on Health and Safety Code §1569.49. At this time, the civil penalty assessment is under review. LPA will return at a future date to assess a civil penalty, if warranted. Staff did not seek medical attention for resident in care in a timely manner.

Appeals rights issued.
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 10
Control Number 59-AS-20240129085315
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: 12/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/13/2024
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 12/13/2024, 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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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: 12/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 10
Control Number 59-AS-20240129085315
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: 12/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/10/2025
Section Cited
CCR
87211(a)(1)
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Reporting Requirements: Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: A written report shall be submitted to the licensing agency and to the person responsible for the resident and to the person responsible
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By 01/10/2025, the licensee shall submit a written report regarding their understanding of when to report incidents to Community Care Licensing Division
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 for the resident within seven days of the occurrence This was not met as evidenced by: Based on file review the licensee did not submit a written notice regarding the resident being hospitalized. This poses a possible risk to residents 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: 12/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 10
Control Number 59-AS-20240129085315
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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The Department investigated an allegation that staff at the facility were not adequately trained. The investigation focused on the period from the facility’s opening to November 2023. A review of staff training records revealed that, during this time, two staff members had only completed the initial required training under Title 22 regulations and the California Health and Safety Code in 2021, with no evidence of the mandatory annual training. Additionally, one staff member had no training documented. A deficiency related to this issue was cited during a case management visit on November 22, 2023. Following the citation, the licensee took corrective action, and as of November 2023, all staff have completed the required training in compliance with Title 22 regulations and the California Health and Safety Code. As the licensee addressed the prior deficiency, the current allegation is substantiated, but no additional deficiency is being issued.
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: 5 of 10
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
01/29/2024 and conducted by Evaluator Kerry Hiratsuka
COMPLAINT CONTROL NUMBER: 59-AS-20240129085315

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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1. Staff member physically abused a resident in care.
2. Staff did not ensure that residents grooming needs were met while in care.
3. Staff did not ensure that resident was provided their medication(s) as prescribed.
4. Staff are unable to communicate with residents in care due to a language barrier.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kerry Hiratsuka, conducted this unannounced complaint visit to deliver the results of the allegations above. The above allegations regard the time frame from the facility opening to November 2023.

1. The department conducted an investigation based on a complaint alleging that a staff member physically abused R1. The investigation included interviews with facility staff, residents, and the witness. During the investigation, a witness reported observing an unexplained bruise and a cut on the hand of R1, alleging the injuries resulted from abuse by two staff members. The administrator recalled R1 having a cut on the hand and stated R1 told the witness that the injury occurred while standing up in the bathroom. The witness further alleged that one of the staff members slapped R1.
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: 6 of 10
Control Number 59-AS-20240129085315
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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The administrator denied the presence of a staff member by the alleged name working at the facility. Additionally, the licensee and administrator both stated they were not informed of any incidents of staff abusing R1. The department attempted to identify the caregiver accused of the abuse but was unable to verify the identity of the individual. Interviews with a second staff member and other residents present during the time frame provided no corroboration of the abuse. One resident declined to participate in the interview process. The department reviewed all available information, including conflicting statements from the involved parties. Due to the inability to verify the identity of the alleged caregiver, corroborate the abuse claims, or obtain additional evidence, the department is unable to substantiate or refute the allegation therefore the above allegation is unsubstantiated.

The Department conducted an investigation into the allegation that staff failed to ensure R1’s grooming needs were met while in care. As part of the investigation, the Department conducted interviews with residents and staff. Unfortunately, Resident 1 (R1) could not be interviewed or observed regarding their grooming care, as R1 had passed away before the investigation. Staff members interviewed denied the allegation, asserting that R1’s grooming needs, including nail care, had been appropriately addressed. The allegation included claims that R1’s toenails were not maintained and that a witness had to provide nail care for R1. However, during observations of other residents in care, there were no indications of neglect or unmet grooming needs. Based on the available evidence, the Department did not find corroboration of the alleged failure to meet grooming standards. 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: 7 of 10
Control Number 59-AS-20240129085315
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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The Department investigated an allegation that staff failed to ensure Resident 1 (R1) received their medications as prescribed. As part of the investigation, the Department obtained and reviewed R1’s medication administration records (MARs). The records indicated that medications were administered as prescribed while R1 was at the facility. Staff reported that on the R1’s final day at the facility, R1 refused to take their medication. The Department was unable to verify the condition of the medication containers, as they were no longer at the facility at the time of the investigation. The allegation also included claims that the medication bottles were either full or contained an excessive number of pills when R1 moved out. However, without access to the medication containers during the investigation, the Department could not confirm this claim. Based on the evidence available, the Department was unable to substantiate or refute the allegation that R1 was not provided their medications as prescribed. 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.

The Department investigated an allegation that staff at the facility were unable to communicate effectively with R1 due to a language barrier, potentially impacting the quality of care. It was alleged on November 21, 2023, R1 was feeling unwell required assistance from staff and that the resident’s condition had been worsening over several days, yet staff failed to take appropriate action. It was further alleged that a primary caregiver’s inability to speak English contributed to the lack of care provided. Based on a review of staff records and interviews conducted with residents, the Licensee, the Administrator, and staff working during the specified time frame it was discovered that there were several caregivers with limited English proficiency. However, the investigation was unable to substantiate whether the language barrier directly interfered with the care provided to R1. Based on the evidence gathered, the Department finds that the allegation is 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: 8 of 10
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
01/29/2024 and conducted by Evaluator Kerry Hiratsuka
COMPLAINT CONTROL NUMBER: 59-AS-20240129085315

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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1. Neglect contributed to resident's death.
2. Staff did not adequately care for the resident, resulting in the resident becoming severely dehydrated while in care.
3. Licensee accepted a resident with a higher level of care needs.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kerry Hiratsuka, conducted this unannounced complaint visit to deliver the results of the allegations above. The above allegations regard the time frame from the facility opening to November 2023.

1. The Department conducted an investigation into allegations related to neglect contributing to R1’s death.
Based on the investigation, the Department obtained and reviewed medical records and R1’s death certificate. The primary cause of death listed was noted as a contributing condition but not the underlying cause. Additionally, hospital records indicated that the facility’s timing in sending R1 to the hospital was not a contributing factor to R1’s death. Based on the evidence gathered, the Department finds that the allegation is unfounded. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.
Unfounded
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: 9 of 10
Control Number 59-AS-20240129085315
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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2. The Department conducted an investigation into the allegation. The investigation included a review of R1’s medical records, hospital records, and interviews with relevant parties. Based on a review of the medical and hospital records, there was no documentation or indication in these records that R1 was dehydrated upon admission or during care. Interviews conducted during the investigation included staff members, facility management, and other relevant parties. A witness stated that R1 appeared severely dehydrated on the day they were sent to the hospital. However, the facility staff denied this claim, indicating that R1’s condition was regularly monitored, and no signs of severe dehydration were observed prior to the transfer. The Department noted that the accounts provided during interviews were inconsistent. The witness’ assertion of severe dehydration conflicts with the medical documentation reviewed, which did not support this claim. Based on the evidence gathered, the Department finds that the allegation is unfounded. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

3. The Department investigated an allegation that the Licensee accepted a resident whose care needs exceeded the level of care the facility could provide during the time frame from the facility’s opening to November 2023. Based on the investigation, the Department reviewed R1’s file, including the pre-admission appraisal. Pre-placement admission appraisal indicated that R1 was able to walk with a walker, able to eat with minimal assistance and supervision, required assistance with showering and using the bathroom, assistance with preparing medication and supervision when taking medication, and required a special diet. Based on the documentation at the time of admission, R1 was assessed to require assistance that fell within the facility’s capabilities under Title 22 Regulations. Based on the evidence gathered, the Department finds that the allegation is unfounded. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.
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: 10 of 10