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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 292700563
Report Date: 10/08/2026
Date Signed: 10/08/2026 12:01:18 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/25/2026 and conducted by Evaluator Cassandra Mikkelson
COMPLAINT CONTROL NUMBER: 59-AS-20260825111947
FACILITY NAME:CASCADES OF GRASS VALLEYFACILITY NUMBER:
292700563
ADMINISTRATOR:HALEY PARKERFACILITY TYPE:
740
ADDRESS:415 Sierra College DRTELEPHONE:
(530) 272-8002
CITY:Grass ValleySTATE: CAZIP CODE:
CAPACITY:65CENSUS: 53DATE:
10/08/2026
UNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Haley ParkerTIME COMPLETED:
12:05 PM
ALLEGATION(S):
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Staff mismanaged resident's medications resulting in resident being over medicated
INVESTIGATION FINDINGS:
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Licensed Program Analyst (LPA) Cassandra Mikkelson arrived at the facility unannounced and met with Executive Director Haley Parker to deliver findings for the above complaint allegation.

During the investigation, LPA conducted interviews, conducted a tour of the facility, and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

*** Report continued on 9099-C***
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cassandra Mikkelson
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 59-AS-20260825111947
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 10/08/2026
NARRATIVE
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Staff mismanaged resident's medications resulting in resident being over medicated

Interviews conducted indicated that R1 was given R2’s medication accidently, although both R1 and R2 are prescribed the same medication. Records reviewed indicated that both R1 and R2 are prescribed the same medication and R1 is also prescribed the medication as a PRN (as needed). On 07/22/2026, a med tech gave R1 R2’s medication, which meant that R1 received the medication earlier than she normally would have per R1’s medication list. R1 appeared to be drowsy due to medication being given sooner than the medication prescribed time which was bedtime for R1. No adverse reactions occurred with R1 for receiving the medication dose at the wrong time. Therefore, the allegation is substantiated.

Based on the information obtained for the allegations above, the allegations are SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Exit interview conducted with Executive Director and a copy of the report and appeal rights was provided.

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cassandra Mikkelson
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 59-AS-20260825111947
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/08/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/15/2026
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed.
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Facility has completed re-training for staff when incident occurred. No POC is due at this time as it was sent to LPA after incident occurred.
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This was not met by evidenced by:
Staff gave the wrong medication to R1.
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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: Laura Munoz
LICENSING EVALUATOR NAME: Cassandra Mikkelson
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/25/2026 and conducted by Evaluator Cassandra Mikkelson
COMPLAINT CONTROL NUMBER: 59-AS-20260825111947

FACILITY NAME:CASCADES OF GRASS VALLEYFACILITY NUMBER:
292700563
ADMINISTRATOR:HALEY PARKERFACILITY TYPE:
740
ADDRESS:415 Sierra College DRTELEPHONE:
(530) 272-8002
CITY:Grass ValleySTATE:CAZIP CODE:
CAPACITY:65CENSUS: 53DATE:
10/08/2026
UNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Haley ParkerTIME COMPLETED:
12:05 PM
ALLEGATION(S):
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Staff did not provide adequate supervision resulting in resident shoving another resident causing injuries
Staff did not ensure resident's diapering needs were met resulting in resident developing a UTI.
Staff did not treat resident with dignity and respect.
INVESTIGATION FINDINGS:
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Licensed Program Analyst (LPA) Cassandra Mikkelson arrived at the facility unannounced and met with Executive Director Haley Parker to deliver findings for the above complaint allegations.

During the investigation, LPA conducted interviews, conducted a tour of the facility, and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

*** Report continued on 9099-C***


Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cassandra Mikkelson
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 59-AS-20260825111947
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 10/08/2026
NARRATIVE
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Staff did not provide adequate supervision resulting in resident shoving another resident causing injuries

Interviews conducted indicated that there was an incident that occurred regarding Resident R1 and R2. R1 was up wandering and staff had helped R1 back to their room. Staff then heard yelling coming from R1 and R2’s room (R1 and R2 share a room). R2 was seen slightly pushing R1 out of their doorway as R1 was attempting to enter R2’s room. The push caused R1 to fall backward into the wall, falling on their buttock and hitting their head on the wall. Staff had entered the room when they heard yelling and witnessed the incident. Staff immediately separated the two residents and called emergency services for R1 due to fall. Records reviewed indicated both R1 and R2 reside in the memory care unit of the facility. No other incidents had occurred between either of the residents in care. Therefore, the allegation staff did not provide adequate supervision resulting in resident shoving another resident causing injuries is unfounded.

Staff did not ensure resident's diapering needs were met resulting in resident developing a UTI

Interviews conducted indicated that R1 was at baseline for toileting. R1 was independent and able to use the toilet on their own without assistance of staff. Staff monitored for signs of UTI or change in baseline. Records reviewed indicated that R1 did not have signs or symptoms of a UTI at the facility. Progress notes indicated that R1 was at baseline for toileting and was able to use the toilet on their own. Therefore, the allegation Staff did not ensure resident's diapering needs were met resulting in resident developing a UTI is unfounded.

Staff did not treat resident with dignity and respect

Interviews conducted indicated that staff treat residents in care with dignity and respect. Staff have received training on the dignity of residents in care. Staff speak and interact with residents in care in a respectful was in order to care for their needs. Residents in care are happy with the care being received and do not have any complaints about the care being provided by staff. Therefore, the allegation staff did not treat resident with dignity and respect is unfounded.

Based on records reviewed and interviews, LPA finds the above allegations to be UNFOUNDED- meaning that the allegations were false, could not have happened and/or is without reasonable basis. Exit interview conducted with the Administrator. Copy of report was given to facility.

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cassandra Mikkelson
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5