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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515002742
Report Date: 11/15/2023
Date Signed: 11/15/2023 02:50:59 PM


Document Has Been Signed on 11/15/2023 02:50 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:KAUR, RAJVEERFACILITY TYPE:
740
ADDRESS:920 BOGUE ROADTELEPHONE:
(530) 777-6476
CITY:YUBA CITYSTATE: CAZIP CODE:
95991
CAPACITY:6CENSUS: 5DATE:
11/15/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Rajveer KaurTIME COMPLETED:
03:00 PM
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Licensing Program Analysts (LPA) Hiratsuka and Yang, conducted this visit to discuss deficiencies cited on 11/02/2023.
LPA Hiratsuka issued a citation because staff did not have medication training as required by California Health and Safety Code §1569.69(a)(2) Employees assisting residents with self-administration of medication; training requirements:. The plan of correction for the licensee was required to be submitted on 11/03/2023. Licensee submitted it on 11/10/2023. Civil penalties issued because the plan of correction wasn't submitted until 11/10/2023.

California Health and Safety Code section §1569.625(b)(2), was cleared as of 11/10/2023, because Licensee submitted proof of purchasing training.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2023
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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