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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
515002742
Report Date:
08/02/2023
Date Signed:
08/02/2023 08:40:26 AM
Document Has Been Signed on
08/02/2023 08:40 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
,
9835 GOETHE ROAD, SUITE 100
SACRAMENTO
,
CA
95827
FACILITY NAME:
YUBA SUTTER CARE HOME INC.
FACILITY NUMBER:
515002742
ADMINISTRATOR:
KAUR, RAJVEER
FACILITY TYPE:
740
ADDRESS:
920 BOGUE ROAD
TELEPHONE:
(530) 777-6476
CITY:
YUBA CITY
STATE:
CA
ZIP CODE:
95991
CAPACITY:
6
CENSUS:
5
DATE:
08/02/2023
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
08:30 AM
MET WITH:
Babita "Nisha" Sharma
TIME COMPLETED:
08:45 AM
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LPA Hiratsuka, conducted this visit. LPA obtained a resident's file and is removing it to make a copy. LPA will return today to return the file.
No deficiencies cited.
SUPERVISOR'S NAME:
Troy Ordonez
TELEPHONE:
(916) 263-4700
LICENSING EVALUATOR NAME:
Kerry Hiratsuka
TELEPHONE:
(916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE:
08/02/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/02/2023
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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