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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 292700563
Report Date: 02/21/2023
Date Signed: 02/21/2023 01:56:41 PM


Document Has Been Signed on 02/21/2023 01:56 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
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926



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: 43DATE:
02/21/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Haley ParkerTIME COMPLETED:
01:30 PM
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LPA Parks arrived on Tuesday February 21, 2023 to conduct a case management visit. 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.

This is a follow up visit for an incident that occurred on 2/14/2023. As R1 was eating dinner, he began to choke. S1 performed the Heimlich maneuver. After the abdominal thrusts were unsuccessful, S2 began to perform CPR per the 911 operator's instructions. Approximately two minutes later, paramedics arrived and took over. R1 was transported to the hospital. R1 passed away on 2/15/2023.

LPA interviewed S2 who was present during the incident. Additionally, R1’s spouse (R2) was interviewed.

LPA obtained R1's physicians report, care plan, and copies of staff CPR/First aid certificates. LPA also obtained contact information for one staff and one visitor who assisted during the incident.

No deficiencies were cited. Exit interview conducted.

SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2023
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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