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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 292700563
Report Date: 11/07/2025
Date Signed: 11/07/2025 09:18:37 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/29/2025 and conducted by Evaluator Cassandra Mikkelson
COMPLAINT CONTROL NUMBER: 59-AS-20251029124754
FACILITY NAME:CASCADES OF GRASS VALLEYFACILITY NUMBER:
292700563
ADMINISTRATOR:HALEY PARKERFACILITY TYPE:
740
ADDRESS:415 SIERRA COLLEGE DRIVETELEPHONE:
(530) 272-8002
CITY:GRASS VALLEYSTATE: CAZIP CODE:
95945
CAPACITY:65CENSUS: 62DATE:
11/07/2025
UNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:TIME COMPLETED:
09:15 AM
ALLEGATION(S):
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Staff did not provide adequate supervision resulting in resident wandering away from facility.
INVESTIGATION FINDINGS:
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Licensed Program Analyst (LPA) Cassandra Mikkelson sent a copy of report for hard signature due to missing 9099-D page. 9099-D was discussed with Executive Director but due to error, it did not save. Executive Director will return to LPA with signature.

During the investigation, LPA conducted interviews, conducted a tour of the facility, and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

*** Report continued on 9099-C***
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Laura Munoz
NAME OF LICENSING PROGRAM ANALYST: Cassandra Mikkelson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 59-AS-20251029124754
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 VALLEY
FACILITY NUMBER: 292700563
VISIT DATE: 11/07/2025
NARRATIVE
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Staff did not provide adequate supervision resulting in resident wandering away from facility.

Interviews conducted and LIC624 incident report submitted indicated that Resident R1 wandered out of the facility on 10/29/2025 and was found down the street by a staff member coming to work. R1 resides in the memory care unit at the facility. Therefore, the allegation that staff did not provide adequate supervision resulting in resident wandering away from facility is substantiated.

Based on the information obtained for the allegations above, the allegation is SUBSTANTIATED- A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Exit interview conducted with Executive Director and a copy of the report and appeal rights was provided.

NAME OF LICENSING PROGRAM MANAGER: Laura Munoz
NAME OF LICENSING PROGRAM ANALYST: Cassandra Mikkelson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 59-AS-20251029124754
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 VALLEY
FACILITY NUMBER: 292700563
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/10/2025
Section Cited
CCR
87411(a)
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87411 Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports...
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Executive Director has already completed retraining of staff. ED submitted to LPA during visit.
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This requirement was not met by evidenced by: On 10/29/2025, Resident R1 eloped from the facility and was found by a staff member who was coming in to work.
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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.
NAME OF LICENSING PROGRAM MANAGER: Laura Munoz
NAME OF LICENSING PROGRAM ANALYST: Cassandra Mikkelson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3