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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 292700563
Report Date: 08/22/2023
Date Signed: 08/24/2023 01:43:22 PM


Document Has Been Signed on 08/24/2023 01:43 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: 57DATE:
08/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Haley ParkerTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Melissa Parks and Associate Governmental Program Analyst (AGPA) Katie Keith arrived on Tuesday August 22, 2023 to conduct the unannounced annual inspection.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA and AGPA reviewed resident (8) and staff (8) files. All resident files contained the required paperwork. All staff files contained the required paperwork and training. Facility is complaint with fire drills. Additionally, LPA reviewed elopement drills.

LPA, AGPA, and Executive Director toured the facility together to ensure the health and safety of residents in care. The areas toured included memory care apartments, memory care common areas, memory care courtyard, assisted living apartments, assisted living courtyard, lobby, kitchen, and laundry rooms. LPA and AGPA observed the facility's emergency food, water storage and PPE. All water temperatures were within the required range. LPA and AGPA observed unlocked over the counter medication in a cabinet in the first floor hallway (pictures taken). See 809-D for citation.

LPA requested an updated copy of LIC610E, LIC500, and current liability insurance by 8/31/2023.

Exit interview conducted. Appeal rights were given. A copy of this report was emailed to the Administrator.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2023
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 08/24/2023 01:43 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 08/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having over the counter medication (sudafed, Tylenol, Excedrin) in an unlocked cabinet in the first floor hallway, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2023
Plan of Correction
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Administrator agrees to send LPA flyer with date/time of staff training regarding locking all medication. Administrator agrees to send LPA staff sign in sheet once training is completed.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2023
LIC809 (FAS) - (06/04)
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