292700563-2-5-2021-27-AS-KHOS-BY3TPU-20210209135455

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 292700563
Report Date: 02/05/2021
Date Signed: 02/05/2021 01:46:09 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/04/2020 and conducted by Evaluator Melissa Lusby

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20200904144054

FACILITY NAME:	CASCADES OF GRASS VALLEY		FACILITY NUMBER:	292700563
ADMINISTRATOR:	PITTMAN, PEPSI		FACILITY TYPE:	740
ADDRESS:	415 SIERRA COLLEGE DRIVE		TELEPHONE:	(530) 272-8002
CITY:	GRASS VALLEY	STATE: CA	ZIP CODE:	95945
CAPACITY:	65	CENSUS: 50	DATE:	02/05/2021
		UNANNOUNCED	TIME BEGAN:	01:35 PM
MET WITH:	Pepsi Pittman		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Residents medications are missing
Residents are only getting changed once a day
Staff are stealing residents personal belongings
Staff are not properly trained

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Melissa Lusby contacted the facility via telephone to conclude a complaint investigation on 2/5/2021 due to COVID-19 and pre-cautionary measures. LPA identified herself and discussed the purpose of the call and the elements of the allegations with Administrator Pepsi Pittman.

Based on LPAs interviews and review of documentation, the preponderance of evidence standards was not met, therefore, the above allegations are found to be UNFOUNDED. An unfounded allegation means that the allegation was false, could not have happened and/or is without a reasonable basis. LPA Lusby conducted an exit interview. LPA Lusby emailed Administrator Pepsi a copy of the report to review, sign, and send back. A signed copy of this report will be stored in the facility file.

Unfounded

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Melissa Lusby	TELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:	DATE: 02/05/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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