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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 292700563
Report Date: 09/11/2024
Date Signed: 09/11/2024 01:55:48 PM


Document Has Been Signed on 09/11/2024 01:55 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: 56DATE:
09/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Haley Parker, AdministratorTIME COMPLETED:
02:10 PM
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Licensing Program Analysts (LPAs) Michael Hood and Cassie Mikkelson arrived at the facility unannounced on 9/11/24 to conduct a Required-1 Year Inspection utilizing the inspection tool.

LPAs conducted an inspection of the care home to ensure compliance with Title 22 regulations. LPAs observed seven (7) apartments in Assisted Living, four (4) apartments in Memory Care, and two (2) common area bathrooms. LPAs observed apartments to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition, properly maintained, and the hot water temperature was observed to be 117.4 degrees F.

LPAs checked the kitchen area for the ability to prepare and store food. Care home has required (2) two-day perishable and (7) seven-day non-perishable food supply on hand. LPAs observed the perimeter of the care home to be free of clutter and debris. LPAs ensured that delayed egress in Memory Care was operational. Smoke detectors are hard wired in the care home and LPAs observed carbon monoxide detectors to be operational in the care home. Fire extinguishers are maintained and ready for emergency use. LPAs reviewed four (4) resident files and four (4) staff files during visit.

First aid kit is maintained and ready for emergency use. LPAs checked medication storage and found medication to be locked away and inaccessible to the residents. Facility has a current copy of certificate of liability insurance and LPAs obtained a copy.

As a result of this visit, no deficiencies were cited per California Code of Regulations, Title 22. Exit was interview conducted and copy of report given at the conclusion of this visit.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:
DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2024
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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