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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515002742
Report Date: 11/02/2023
Date Signed: 11/02/2023 10:45:45 AM


Document Has Been Signed on 11/02/2023 10:45 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, RAJVEERFACILITY TYPE:
740
ADDRESS:920 BOGUE ROADTELEPHONE:
(530) 777-6476
CITY:YUBA CITYSTATE: CAZIP CODE:
95991
CAPACITY:6CENSUS: 6DATE:
11/02/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:12 AM
MET WITH:Babita "Nisha" SharmaTIME COMPLETED:
11:00 AM
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While investigating a complaint LPA Hiratsuka observed the following deficiencies:
California Health and Safety Code Section §1569.69(a)(2) Employees assisting residents with self-administration of medication; training requirements: In facilities licensed to provide care for 15 or fewer persons, the employee shall complete six hours of initial training. This training shall consist of two hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and four hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment.

No proof have had the required medication training as well as the required annual training.

California Health and Safety Code section §1569.625(b)(2) Staff training; legislative findings; contents:(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

File reviews for two staff show they have the initial training required per the Health and Safety Code, but do not have any annual training since 2021.

Licensee has not paid their annual fees. The annual fees are due by March 19th of each year. The licensee owes $716.50, which includes overdue fees.

Deficiencies cited from Title 22 Regulations and or the California Health and Safety Code. Failure to correct shall result in civil penalties. appeal rights left
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2023
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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Document Has Been Signed on 11/02/2023 10:45 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, 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: 11/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/17/2023
Section Cited
HSC
1569.625(b)(2)

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Staff training; legislative findings; contents. In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to
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By 11/17/2023, licensee shall submit a written plan of correction how they shall ensure all staff have the required training and ensure the current staff have the required training.
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postural supports, restricted health conditions, and hospicecare, as required by subdivision (a) of Section 1569.696. Based on record review, the licensee did not comply with the section cited above because two current staff did not/does not have the initial training which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
11/10/2023
Section Cited
CCR87156(b)(1)(F)

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Licensing Fees. In addition to fees set forth in subdivision (a), the department shall charge the following fees: A late fee that represents an additional 50 percent of the established annual fee when any licensee fails to pay the annual licensing
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By 11/10/2023, licensee shall pay their annual fee and overdue fee and shall submit a written plan of correction stating how they shall ensure their annual fees are paid by the due date each year.
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fee on or before the due date as indicated by postmark on the payment. Based on record review, the licensee did not comply with the section cited above because the annual fees are overdue which poses/posed a potential 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: 11/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/02/2023 10:45 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, 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: 11/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/03/2023
Section Cited
HSC
1569.69(a)(2)

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Employees assisting residents with self-administration of medication; training requirements. In facilities licensed to provide care for 15 or fewer persons, the employee shall complete six hours of initial training...
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By 11/03/2023, the staff who prepare and distribute medication shall have the required medication training which includes shadow training. Licensee shall submit a written plan of correction how they shall ensure staff are trained per the California Health and Safety Code each year.
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Based on record review, the licensee did not comply with the section cited above because there is no proof staff have had medication training 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: 11/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2023
LIC809 (FAS) - (06/04)
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