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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 292700563
Report Date: 11/21/2024
Date Signed: 11/21/2024 02:20:07 PM

Document Has Been Signed on 11/21/2024 02:20 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:CASCADES OF GRASS VALLEYFACILITY NUMBER:
292700563
ADMINISTRATOR/
DIRECTOR:		HALEY PARKERFACILITY TYPE:
740
ADDRESS:415 SIERRA COLLEGE DRIVETELEPHONE:
(530) 272-8002
CITY:GRASS VALLEYSTATE: CAZIP CODE:
95945
CAPACITY: 65CENSUS: 64DATE:
11/21/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Haley Parker, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Administrator, Haley Parker, to conduct a case management visit. The purpose of today's visit is to follow up on an Unusual Incident/Injury Report (SIR) that was received by the Department on 11/21/2024.

On 11/18/2024, at 7:53 am, staff alerted nurse on shift that back gate alarm was activated and, after conducting a room to room sweep of the Memory Care Unit, staff were unable to locate resident (R1). Staff began searching the surrounding area and were unable to locate R1. At 8:08 am, facility contacted 9-1-1 to file a missing person's report as well as R1's family. R1 was located at city hall at approximately 8:21 am and returned to the facility. R1 was assessed to have no injuries due to incident.

R1's LIC 602A dated 11/02/2024 indicates R1 has a diagnosis of dementia. R1's LIC 602A indicates that R1 is unable to leave the facility unassisted with a note saying "facility discretion, was driving before."

As a result of today's inspection, a deficiency is being cited pursuant to California Code of Regulations, Title 22, Section 87705(c)(4) regarding care and supervision of residents with dementia. The deficiency is listed on 809-D.

Exit interview was conducted with Administrator. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2024
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 11/21/2024 02:20 PM - It Cannot Be Edited


Created By: Michael Hood On 11/21/2024 at 02:11 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CASCADES OF GRASS VALLEY
FACILITY NUMBER: 292700563

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/22/2024
Section Cited
CCR
87705(c)(4)

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87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. This requirement is not met as evidenced by:
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Facility will install a secondary alarm to the egress gate in the Memory Care Unit courtyard area. Facility will also conduct a training with staff regarding supervision. Facility will submit training materials and date of training to LPA by POC due date.
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Based on records reviewed, the facility did not ensure that residents R1 was properly supervised, resulting in an AWOL, which poses an immediate health, safety, and personal rights risk to residents 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:Anthony Perez
LICENSING EVALUATOR NAME:Michael Hood
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2024


LIC809 (FAS) - (06/04)
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