Inspection visit

Follow-up on correctionsNovember 15, 2023

YUBA SUTTER CARE HOME INC.License 51500274210 citations on this visit

10 citations recorded

Inspector’s narrative

What the inspector wrote

While investigating Complaints 59-AS-20230731122901 and 59-AS-20230717132508, the following deficiencies were observed: 1. The facility staff (S1) that works overnight does not provide any incontinent care to the residents. S1 stated they do not check to see if a resident who requires assistance with incontinence care nor does S1 change the resident out of soiled clothes and briefs. Interviews show S1 does not respond to residents who request assistance during the overnight hours. The facility file does not have any staff training required by Title 22 regulations regarding night supervision. There is no proof S1 has first aid training and training to assist in caring for residents in the event of an emergency. California Health and Safety Code states the licensee may designate a qualified substitute in place of the administrator who has to be present on the premises 24 hours per day and that qualified substitute shall have qualifications adequate to be responsible and accountable for the management and administration of the facility. The staff member on duty overnight does not meet these requirements. There is no proof of any training to ensure the person is qualified. 2. A resident (R1) was on home health during the resident’s stay. The facility is required to have a copy of a written agreement of what the facility staff are to do and what the home health care agency is supposed to do. That was not found in the resident’s file . 3. The facility is required to have ongoing communication between themselves and the home health care agency. That was not found in R1’s file. 4. R1 developed a pressure injury during a hospital stay and was admitted with the pressure injury. The facility did not document R1 had a pressure injury. The licensee is required to do a preappraisal and a reappraisal when there is a change in condition. There is no documentation stating R1 had a pressure injury and what was being done about it. 5. Prior to accepting a resident the licensee is required to do a functional capability assessment. There was no document in R1’s file stating it was done. 6. Title 22 regulations requires certain documentation to be in a resident’s file. A medical assessment is required to be in the resident’s file. S2 stated one was completed but was given to emergency personnel who took R1 to the hospital and it was not replaced. LPA was unable to review a medical assessment of the resident due to it not being in the file and not replaced. 7. Title 22 regulations requires a centrally stored medication log or list of medications the resident is prescribed to take. S2 stated she gave the list to the emergency personnel who took R1 to the hospital and did not replace it. 8. The administrator has demonstrated they do not have the knowledge to operate a facility based on the above issues that are being cited. The administrator also is being cited because a pressure injury that occurred at a hospital became worse while the resident was at the facility due to neglect of the staff. The staff did not change the resident out of soiled clothing and diapers. Licensee did not ensure staff who work the overnight shift check and change residents who require incontinent care. Licensee does not ensure there is a staff person working on each shift that is capable of communicating with home health agency staff, Community Care Licensing staff, and emergency personnel. S1 has to call another staff person when they are left alone for someone to come to the facility to communicate with others. 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

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 other inspection of YUBA SUTTER CARE HOME INC. on November 15, 2023. 10 citations were issued: 3 Type A (serious) and 7 Type B.

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

Yes, 10 citations were issued (3 Type A, 7 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 other inspection. other inspections are conducted by CCLD as part of their licensing oversight.

SourceView on CCLD View original report

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Data from CCLD public records. Last updated May 25, 2026. If you believe any information is inaccurate, report it here.

Follow-up on corrections·November 15, 2023