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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 292700563
Report Date: 10/17/2024
Date Signed: 10/17/2024 02:50:08 PM


Document Has Been Signed on 10/17/2024 02:50 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: 55DATE:
10/17/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Haley Parker, AdministratorTIME COMPLETED:
03:05 PM
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Licensing Program Analysts (LPAs) Michael Hood and Cassie Mikkelson arrived at the facility and met with Administrator, Haley Parker, to follow-up regarding fire clearance concerns during an annual inspection conducted on 9/11/2024.

During today's visit, LPAs conducted a tour of the Memory Care Unit of the facility. LPAs will be requesting that facility add a delayed egress gate to the Memory Care Unit. Facility will follow-up with LPAs regarding expected time frame to install door and status updates.

No deficiencies were cited per Title 22 during inspection. Exit interview was conducted with Administrator. 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: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2024
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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