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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 292700563
Report Date: 01/30/2023
Date Signed: 01/30/2023 02:03:55 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/31/2022 and conducted by Evaluator Melissa Parks
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20221031095122
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: 47DATE:
01/30/2023
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Mary Mims-BurrisTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility food storage is not properly sanitized.
INVESTIGATION FINDINGS:
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LPA Parks arrived on Monday January 30, 2023 to conclude the investigation regarding the above allegation. 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.

Throughout the course of the investigation, LPA interviewed staff including Administrator, Business Office Director, Food Service Director and kitchen staff. Additionally, LPA interviewed the Nevada County Evnironmental Health officer. LPA also toured the kitchen including walk-in refrigerator, walk-in freezer, and food storage room. LPA observed the following during the initail complaint visit: food and dirt under prep tables and stains on walls and ceilings in the kitchen (pictures taken). Kitchen staff interviewed could not provide LPA with a cleaning schedule. Additionally, the Administrator at the time of the complaint acknowledged that the kitchen's current state was unacceptable and that they would be hiring a company to deep clean.
Substantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2023
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 25-AS-20221031095122
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: CASCADES OF GRASS VALLEY
FACILITY NUMBER: 292700563
VISIT DATE: 01/30/2023
NARRATIVE
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Therefore, the allegation that facility food storage is not properly sanitized is SUBSTANTIATED.
As a result of this investigation, LPA finds the allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies cited on 9099-D. Appeal rights were printed and given.

Exit interview conducted. A copy of this report was left at the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/31/2022 and conducted by Evaluator Melissa Parks
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20221031095122

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: 47DATE:
01/30/2023
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Mary Mims-BurrisTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility refrigerator has mold
Facility staff do not follow proper food handling procedures
Facility staff do not follow proper hand washing procedures
INVESTIGATION FINDINGS:
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LPA Parks arrived on Monday January 30 to conclude the investigation regarding the above allegations. 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.

Throughout the course of the investigation, LPA interviewed staff including Administrator, Business Office Director, Food Service Director, kitchen staff and care staff. Additionally, LPA interviewed the Nevada County Environmental Health officer. LPA also toured the kitchen including walk-in refrigerator, walk-in freezer, and food storage room. When LPA interviewed the Nevada County Environmental Health officer, she stated that there was a black substance in the refrigerator but was unable to determine if it was mold or dirt. She stated that this was normal in 'high production' kitchens. When LPA conducted a walkthrough of the kitchen, she did observe two boxes on the floor. However, while interviewing the
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 25-AS-20221031095122
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: CASCADES OF GRASS VALLEY
FACILITY NUMBER: 292700563
VISIT DATE: 01/30/2023
NARRATIVE
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Dietary Manager, she learned that this was the day the facility received their food order, and the boxes/food items are being put away. After the food is organized and stored in the appropriate area of the kitchen, no boxes are left on the floor. LPA interviewed dietary staff and care staff who all acknowledged that anyone serving food washes their hands prior to serving.

Based on information obtained during the investigation, LPA finds the allegations to be UNSUBSTANTIATED- a finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred,



Exit interview. Copy of report provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 25-AS-20221031095122
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: CASCADES OF GRASS VALLEY
FACILITY NUMBER: 292700563
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/28/2023
Section Cited
CCR
87303(a)
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Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times. . . this requirement was not met as evidenced by dirt, food, and stains on refrigerator, pantry, and kitchen floor. This poses an indirect threat to the health and safety of residents in care.
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Facility to provide LPA with a cleaning schedule by POC date 2/28/2023
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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: 01/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5