<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515002742
Report Date: 04/24/2023
Date Signed: 04/24/2023 11:03:39 AM


Document Has Been Signed on 04/24/2023 11:03 AM - 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



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:
04/24/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Babita Sharma, CaregiverTIME COMPLETED:
11:15 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to complete a POC visit. LPA met with Caregiver Babita Sharma during today's inspection, and LPA spoke to administrator over the phone.

During today's visit, LPA observed the side gate to be locked with a padlock. In addition, LPA observed smoke detector chirping due to low battery. LPA to cite deficiencies on 809-D and civil penalties assessed.

All other deficiencies cited during the annual inspection on 3/06/23 have been cleared. Letter of clearance has been given and copy of report given.

Exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:
DATE: 04/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 04/24/2023 11:03 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833


FACILITY NAME: YUBA SUTTER CARE HOME INC.
FACILITY NUMBER: 515002742

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/25/2023
Section Cited

1
2
3
4
5
6
7
87705 Care of Persons with Dementia. (l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: (2) The licensee shall ensure that the fire clearance includes approval of locked exterior doors or locked perimeter fence gates.
1
2
3
4
5
6
7
Administrator agrees to complete 5 spot checks in the month of May to make sure staff is not placing a lock on the side gate. Once checks have been completed, documentation to be sent into LPA.
8
9
10
11
12
13
14
Based on observation, the licensee did not comply with the section cited above by placing a lock on the side gate without a fire clearance which poses an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
By 4/25/23, Administrator to send a statement of understanding into LPA.

Civil penalties assessed.
Type A
04/25/2023
Section Cited

1
2
3
4
5
6
7
87202 Fire Clearance. (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.
1
2
3
4
5
6
7
Administrator agrees to change the battery of the smoke detector in hallway which leads to resident rooms. Administrator to send LPA a statemtent that smoke
8
9
10
11
12
13
14
Based on observation, the licensee has a smoke detector with a low battery that continuously beeps which poses an immediate health and safety risk to persons in care.
8
9
10
11
12
13
14
detector batteries have been changed by 4/25/23.

Civil penalties assessed.
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) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:
DATE: 04/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2