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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515002742
Report Date: 03/12/2025
Date Signed: 03/12/2025 03:27:45 PM

Document Has Been Signed on 03/12/2025 03:27 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/
DIRECTOR:		KAUR, RAJVEERFACILITY TYPE:
740
ADDRESS:920 BOGUE ROADTELEPHONE:
(530) 777-6476
CITY:YUBA CITYSTATE: CAZIP CODE:
95991
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
03/12/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:50 PM
MET WITH:Esmeralda NegreteTIME VISIT/
INSPECTION COMPLETED:
03:37 PM
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Licensing Program Analysts (LPA) Kerry Hiratsuka arrived unannounced at the facility to conduct a required annual inspection utilizing the full care tool. LPA met with caregiver, and explained the purpose of the visit.

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

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

LPAs conducted a file review of five (5) residents files and two staff files. LPA observed staff and residents file to be completed.

Multiple topics were discussed during this visit.

No deficiencies cited. Exit interview conducted.
Troy OrdonezTELEPHONE: (916) 263-4700
Kerry HiratsukaTELEPHONE: (916) 591-0210
DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/12/2025
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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