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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 292700563
Report Date: 11/21/2024
Date Signed: 11/21/2024 03:41:46 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
11/15/2024 and conducted by Evaluator Michael Hood
COMPLAINT CONTROL NUMBER: 59-AS-20241115130642
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: 64DATE:
11/21/2024
UNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Haley Parker, AdministratorTIME COMPLETED:
03:55 PM
ALLEGATION(S):
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Licensee did not ensure that facility faucets deliver hot water
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Administrator, Haley Parker, to open a complaint investigation into the allegation listed above.

Interview with Administrator, Maintenance Director (MD), and Wellness Director (WD) indicated that the facility had hot water off and on during the week of 11/10/24 to 11/16/2024, and hot water was fixed on 11/14/2024 in the evening. WD stated that there were no issues providing showers until 11/12/2024, in which some residents received a shower on time and others received a shower on 11/15/2024. Administrator, MD, and staff member (S1) stated that kitchen has a separate water tank that was unaffected by hot water outage and cleaning dishes was not an issue.

** Report continued on 9099-C **
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024
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 2
Control Number 59-AS-20241115130642
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: 11/21/2024
NARRATIVE
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LPA interviewed residents R1, R2, and R3, who stated that they did not recall the facility not having hot water. LPA took the temperature of the water in a common bathroom and observed water temperature to be 111.9 degrees F.

Based on interviews conducted, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Due to facility actively repairing the hot water and correcting the issue in a timely matter, and a lack of residents being affected within a small time frame, no deficiencies are being cited regarding allegation.

Exit interview was conducted with Administrator. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2