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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 292700563
Report Date: 08/08/2022
Date Signed: 08/08/2022 10:54:51 AM


Document Has Been Signed on 08/08/2022 10:54 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:CASCADES OF GRASS VALLEYFACILITY NUMBER:
292700563
ADMINISTRATOR:ROBERT GODFREYFACILITY TYPE:
740
ADDRESS:415 SIERRA COLLEGE DRIVETELEPHONE:
(530) 272-8002
CITY:GRASS VALLEYSTATE: CAZIP CODE:
95945
CAPACITY:65CENSUS: 37DATE:
08/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Robert GodfreyTIME COMPLETED:
11:00 AM
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LPA Parks arrived on Monday August 8, 2022 to conduct the annual inspection. Prior to the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask.

LPA was screened by LVN Haley Parker at the front desk of the facility. LPA and Administrator completed the infection control domain together and facility was found to be in substantial compliance at this time. LPA and Administrator toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to dining room, model apartments, cleaning closet(s), laundry room, PPE supply room, and the Lodge (memory care). In the areas toured, no immediate health, safety, or personal rights violations were observed. Facility has a supply of more than 30 days of full PPE.

LPA requested updated copies of LIC500, LIC610 and current liability insurance.

No deficiencies are being cited as a result of todays inspection. Exit interview conducted. LPA was unable to print a copy of this report at the facility. LPA will email copy of the report to the Administrator on 8/10/2022.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2022
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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