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Inspection visit

complaint

YUBA SUTTER CARE HOME INC.License 5150027423 citations on this visit
3 citations recorded

Inspector’s narrative

What the inspector wrote

R1 was also left in soiled diapers during the day. Staff stated R1 refused to be changed and the R1 stated that is not true. R1 stated they were not changed on a regular basis and R1 also stated R1 said “yes” to staff when staff asked R1 if they needed to be changed but was not changed. No written incontinent care plan was found in R1's file at the facility during a file review. Home health agency staff stated they found R1 in soiled diapers when they visited R1. Staff 2 (S2) also did not seek medical attention when the pressure injury on R1 worsened. S2 stated they were instructed to put cream on the pressure injury and to put a bandage on it if it fell off between the home health care agency checks. S2 stated they contacted the administrator and the responsible party when they noticed the pressure injury smelled bad and did not send R1 to the hospital until being instructed to do so by the responsible party. R1 was sent to the hospital 07/26/2023 and has not returned. Title 22 regulations and California Health and Safety Code do not require staff to speak English. However, the regulations do require staff to be competent to provide services necessary to meet resident needs. LPA Hiratsuka was unable to communicate with two separate staff members. The first time was on 08/02/2023, and that staff member (S3) called S2 who showed up and LPA was able to communicate with S2. During the visit LPA met S1 and LPA was unable to communicate with S1 either. LPA found both S1 and S3 working by themselves. S2 stated they live a couple of minutes away and the others can call S2 at any time. Home health agency staff stated they were unable to communicate with S1 when they had questions and S1 had to call S2 and S2 arrived to finish the visits. S1 is also the overnight staff member. There is no proof S1 can call for emergency services by themself. As a result of this investigation, the Department finds the allegations above to be Substantiated. A finding that the complaint is Substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. At the time of the complaint visit, an immediate civil penalty of $500 shall be assessed for a violation of California Code of Regulations Section 87463(a). The licensee was informed that a civil penalty was under review and may be assessed at a future date according to Health and Safety Code 1569.49. Exit interview conducted. A copy of the report has been issued. Appeal Rights provided. signature on this report acknowledges receipt of the Appeal Rights

Citations

14 citations recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 1569.618(b)Type A

    , Administration and management of residential care facilities; substituted qualifications; employee scheduling. At least one administrator, facility manager, or designated substitute who... has qualifications adequate to be responsible and accountable for the management and administration of the facility pursuant to Title 22 of the California Code of Regulations shall be on the premises 24 hours per day. The designated substitute may be a direct care staff member who shall not be required to meet the educational, certification, or training requirements of an administrator This requirement is not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above because current staff did not/does not proof of required training which poses/posed an immediate health, safety or personal rights risk to persons in care.

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  • 1569.725(a)(3)Type B

    Incidental medical care; residential care facility. A residential care facility for the elderly may permit incidental medical services to be provided through a home health agency, licensed pursuant to Chapter 8 (commencing with Section 1725), when all of the following conditions are met: There is evidence of an agreed-upon protocol between the home health agency and the residential care facility for the elderly... Based on record review, the licensee did not comply with the section cited above because there was no written contract or paperwork between the resident and home health agency, which poses a potential, safety or personal rights risk to persons in care.

  • 1569.725(a)(4)Type B

    Incidental medical care; residential care facility. A residential care facility for the elderly may permit incidental medical services to be provided through a home health agency, licensed pursuant to Chapter 8 (commencing with Section 1725), when all of the following conditions are met: There is ongoing communication between the home health agency and the residential care facility for the elderly about the services provided to the resident by the home health agency and the frequency and duration of care to be provided. Licensee did not comply because there were no records of communication between the facility and the home health care agency.

  • 87405(h)(8)Type B

    Administrator - Qualifications and Duties The administrator shall have the responsibility to: Have the personal characteristics, physical energy and competence to provide care and supervision and, where applicable, to work effectively with social agencies. Based on record review, the licensee did not comply with the section cited above because staff don't have the required training, do not check residents who require incontinent assistance, employing staff who are qualified which poses/posed a potential health, safety or personal rights risk to persons in care.

  • 87415(a)Type A

    Night Supervision The following persons providing night supervision from l0:00 p.m. to 6:00 a.m. shall be familiar with the facility's planned emergency procedures, shall be trained in first aid as required in Section 87465, Incidental Medical and Dental Care Services and shall be available as indicated below to assist in caring for residents in the event of an emergency. This requirement is not met as evidenced by: Based on record and interviews the licensee did comply with this section because S1 stated they do not change residents nor is there proof of emergency training which poses an immediate risk to residents

  • 87459(a)Type B

    Functional Capabilities The facility shall assess the person's need for personal assistance and care by determining his/her ability to perform specified activities of daily living. Such activities shall include, but not be limited- Based on record review, the licensee did not comply with the section cited because there was no functional capability conducted on any of the residents in care poses/posed a potential health, safety or personal rights risk to persons in care.

  • 87505Type B

    Documentation and Support Each facility shall document in writing the findings of the pre-admission appraisal and any reappraisal or assessment which was necessary in accordance with Sections 87457, Pre-admission Appraisal, and 87463, Reappraisals... Based on record review, the licensee did not comply with the section cited because there was no appraisal or reappriasal done on the resident indicating R1 had a wound which poses/posed a potential health, safety or personal rights risk to persons in care.

  • 87506(14)Type B

    Resident Records Each resident’s record shall contain at least the following information: Current centrally stored medications as specified in Section 87465, Incidental Medical and Dental Care Services. This requirement was not met as evidenced by: Based on record review, the licensee did not comply with the section cited above because R1 went to the hospital and the list of medications was sent with the resident and not replaced. which poses/posed a potential health, safety or personal rights risk to persons in care.

  • 87506(b)(10)Type B

    Resident Records. Each resident’s record shall contain at least the following information: Reports of the medical assessment specified in Section 87458, Medical Assessment, and of any special problems or precautions. This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above because R1 went to the hospital and the medical assessment was sent with the resident and not replaced. which poses/posed a potential health, safety or personal rights risk to persons in care.

  • 87625(b)(2)Type A

    Managed Incontinence. In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night. This requirement is not met as evidenced by: Based on interview, the licensee did not comply with the section cited above because S1 stated they do not change residents during the overnight shiff which poses/posed an immediate health, safety or personal rights risk to persons in care.

  • 87411(a)Type A

    Personnel Requirements – General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs… This requirement is not met as evidenced by: Based on interviews and record reviews, the Licensee did not compy with the section cited above because the staff did not seek medical attention and waited to be instructed, nor did the provide incontinent care to residents overnight, and cannot communicate with home health agency staff and CCLD staff which poses/posed an immediate health, safety or personal rights risk to persons in care.

  • 87466Type A

    Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by: Based on interviews and record reviews, the licensee did not comply with the section cited above because the staff did not seek medical attention and waited to be instructed to which poses/posed an immediate health, safety or personal rights risk to persons in care.

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  • 87468.1(a)(2)Type A

    Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above because S1 stated they do not change residents during the overnight shift out of soiled clothes and diapers which poses/posed an immediate health, safety or personal rights risk to persons in care.

  • 87611(b)(1)(D)Type A

    General Requirements for Allowable Health Conditions. The licensee shall complete and maintain a current, written record of care for each resident that includes, but is not limited to, the following: Documentation from the physician of the following: Documentation from the physician of the Resident's ability to perform the procedure; Based on record review, the licensee did not comply with the section because there was no incontinent care plan for any of the residents which poses/posed an immediate health, safety or personal rights risk to persons in care.

FAQ · About this visit

Common questions about this visit

What happened during the November 15, 2023 inspection of YUBA SUTTER CARE HOME INC.?

This was a complaint inspection of YUBA SUTTER CARE HOME INC. on November 15, 2023. 3 citations were issued: 3 Type A (serious).

Were any citations issued to YUBA SUTTER CARE HOME INC. on November 15, 2023?

Yes, 3 citations were issued (3 Type A, 0 Type B). The first citation was for: ", Administration and management of residential care facilities; substituted qualifications; employee scheduling. At lea..."

What type of inspection was this?

This was a complaint inspection. Complaint inspections are triggered when someone reports a concern about the facility to CCLD.

SourceView on CCLDView original report

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Data from CCLD public records. Last updated . If you believe any information is inaccurate, report it here.