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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 292700563
Report Date: 04/16/2024
Date Signed: 04/16/2024 02:53:50 PM


Document Has Been Signed on 04/16/2024 02:53 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:HALEY PARKERFACILITY TYPE:
740
ADDRESS:415 SIERRA COLLEGE DRIVETELEPHONE:
(530) 272-8002
CITY:GRASS VALLEYSTATE: CAZIP CODE:
95945
CAPACITY:65CENSUS: 59DATE:
04/16/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Haley Parker, AdministratorTIME COMPLETED:
03:10 PM
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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 4/8/2024.

On 4/1/2024, staff were alerted by the delayed egress alarm at the back of the facility at approximately 2:20 PM. A head count of the community was completed and it was determined that resident (R1) had left the facility. Staff located the resident outside the facility at the adjacent intersection at approximately 2:28 PM. Resident was then redirected back to the facility by staff. No injuries were observed.

Interview with Administrator indicated that the gate alarm of the delayed egress notified staff and staff immediately swept the parameter of the care home. Administrator confirmed that resident was found at the intersection adjacent to the facility and took about 8 minutes from the time in which the gate alarm activated and the resident was located. Administrator stated that another assessment of R1 will be conducted to better represent R1's behaviors. Administrator stated that facility will have staff present in the courtyard area with residents. Administrator will also follow-up with fire department regarding suggestions to improve delayed egress process.

LPA observed R1's Physician's Report for RCFE LIC 602A dated 6/4/2023, which states that R1 has a diagnosis of dementia and is not able to leave the facility unassisted.

Exit interview was conducted with Administrator. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:
DATE: 04/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2024
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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