292700563-2-21-2023-25-AS-MSEY-CPAN5Q-20230222090951

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 292700563
Report Date: 02/21/2023
Date Signed: 02/21/2023 02:16:52 PM

Unsubstantiated

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
12/30/2022 and conducted by Evaluator Melissa Parks

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20221230145725

FACILITY NAME:	CASCADES OF GRASS VALLEY		FACILITY NUMBER:	292700563
ADMINISTRATOR:	ROBERT GODFREY		FACILITY TYPE:	740
ADDRESS:	415 SIERRA COLLEGE DRIVE		TELEPHONE:	(530) 272-8002
CITY:	GRASS VALLEY	STATE: CA	ZIP CODE:	95945
CAPACITY:	65	CENSUS: 43	DATE:	02/21/2023
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Haley Parker		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Residents are not propperly supervised while in care

INVESTIGATION FINDINGS:

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LPA Parks arrived on February 21, 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, Wellness Director, Assistant Wellness Director, med techs, caregivers, and agency staff. LPA reviewed Physicians’ Reports, care plans and progress notes for R1 and R2. Additionally, LPA reviewed staffing schedules for the months of October, November, and December. Based on interviews and review of documentation, there is sufficient staffing for the memory care unit. Those interviewed acknowledged that there is sufficient staff in order to meet the resident’s needs and provide observation. During the day shift there are two caregivers, one nurse, and activities assistant providing activities throughout the day. On the PM,there are two caregivers,

Unsubstantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa Parks	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

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Control Number 25-AS-20221230145725

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: 02/21/2023

NARRATIVE

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and nurse until 8pm. On the overnight (NOC) shift, there is one caregiver and one med tech who floats between the memory care unit and the assisted living portion of the facility. At the time of the initial complaint, the census for the memory care unit was 15 residents.

Based on information obtained during the investigation, LPA finds the allegation 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. Appeal rights were printed and given along with a copy of this report.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa Parks	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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