Cascades of Grass Valley

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cassandra Mikkelson arrived unannounced and met with Executive Director Haley Parker to conduct an annual inspection utilizing the inspection tool. LPA conducted an inspection of the care facility to ensure compliance with Title 22 regulations. LPA observed resident rooms, common area bathrooms, kitchen, common areas and perimeter of care facility. LPA observed rooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition and properly maintained. LPA checked the kitchen area for the ability to prepare and store food. Care facility has required (2) two day perishable and (7) seven day non-perishable food supply on hand. Smoke detectors and carbon monoxide detectors are operational in the care facility. Fire extinguishers and first aid kit are maintained and ready for emergency use. LPA checked medication carts and found medications to be locked away and inaccessible to the residents. LPA reviewed eight (8) resident files, five (5) staff files and resident medications. Facility has a current copy of certificate of liability insurance and LPA obtained a copy. As a result of this visit, no deficiencies were cited pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8. Exit interview was conducted with Administrator.the state’s words, verbatim · CDSS document, Aug 4, 2026

Allegation investigated: The licensee did not assist in arranging for medical appropriate to the conditions and needs of residents

Licensing Program Analyst (LPA) Cassandra Mikkelson arrived unannounced to continue the investigation into allegations listed above. LPA met with Executive Director Haley Parker, during today’s visit. During today's inspection LPA conducted interviews, toured the facility and reviewed records pertinent to the investigation. The results of the investigation are as follows: *** Report continued on 9099-C*** Unfounded The licensee did not assist in arranging for medical appropriate to the conditions and needs of residents. Interviews conducted with Executive Director (ED) indicated that Resident R1 had experienced issues with their catheter since January 2026. Staff have continuously worked with home health, hospice and R1’s physician to help decrease discomfort/pain that R1 had been experiencing since receiving the catheter. During the most recent event, staff noticed that R1 had more discomfort than usual and had a slight red color to the urine in the catheter bag. Staff reached out the R1’s power of attorney (POA) for next steps/transfer to hospital. R1’s POA requested that R1 not be sent to the hospital and have R1’s urine tested as an outpatient test. Staff reached out to R1’s physician requesting a test to which they declined and told staff that R1 needed to go to the hospital. Staff attempted to explain that it was the request of the POA to not have R1 sent out to the hospital and instead perform a urine test. Documents reviewed indicated that facility staff had sent requests to R1’s physician indicating that R1 was having discomfort with the catheter. Physician responses were documented indicating prescribing of new medications to assist. Daily progress notes indicated that staff were watching R1’s urine output closely and were checking for any signs of infection while also reporting to home health services each day. Staff continued reports to home health, POA and physician’s office until urinalysis order was received on 01/30/2026. Facility staff followed instructions and continued to monitor. Based on records reviewed and interviews, LPA finds the above allegation to be UNFOUNDED- meaning that the allegation was false, could not have happened and/or is without reasonable basis. Exit interview conducted with the Executive Director. Copy of report was given to facility.the state’s words, verbatim · CDSS document, Mar 10, 2026 · control 59-AS-20260212094654

Allegation investigated: Staff did not provide adequate supervision resulting in resident wandering away from facility.

Licensed Program Analyst (LPA) Cassandra Mikkelson sent a copy of report for hard signature due to missing 9099-D page. 9099-D was discussed with Executive Director but due to error, it did not save. Executive Director will return to LPA with signature. During the investigation, LPA conducted interviews, conducted a tour of the facility, and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: *** Report continued on 9099-C*** Substantiated Staff did not provide adequate supervision resulting in resident wandering away from facility. Interviews conducted and LIC624 incident report submitted indicated that Resident R1 wandered out of the facility on 10/29/2025 and was found down the street by a staff member coming to work. R1 resides in the memory care unit at the facility. Therefore, the allegation that staff did not provide adequate supervision resulting in resident wandering away from facility is substantiated. Based on the information obtained for the allegations above, the allegation is SUBSTANTIATED- A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Exit interview conducted with Executive Director and a copy of the report and appeal rights was provided.the state’s words, verbatim · CDSS document, Nov 7, 2025 · control 59-AS-20251029124754

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Nov 10, 2025

87411 Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports... This requirement was not met by evidenced by: On 10/29/2025, Resident R1 eloped from the facility and was found by a staff member who was coming in to work.the state’s words, verbatim · CDSS document, Nov 7, 2025

Plan of correction: Executive Director has already completed retraining of staff. ED submitted to LPA during visit.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Michael Hood arrived at the facility unannounced on 7/10/25 to conduct a Required-1 Year Inspection utilizing the inspection tool. LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. LPA observed 11 apartments in Assisted Living, three (3) apartments in Memory Care, and three (3) common area bathrooms. LPA observed apartments to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition and properly maintained. Hot water temperature was observed to be 120 degrees F. LPA checked the kitchen area for the ability to prepare and store food. Care home has required (2) two-day perishable and (7) seven-day non-perishable food supply on cite. LPA observed the perimeter of the care home to be free of clutter and debris. LPA ensured that delayed egress in Memory Care was operational. Smoke detectors and carbon monoxide detectors are hard wired in the care home. Fire extinguishers and first aid kit are maintained and ready for emergency use. LPA reviewed four (4) resident files and four (4) staff files during visit. LPA reviewed two (2) residents' medications and observed medication storage to be locked away and inaccessible to the residents. Facility has a current copy of certificate of liability insurance and LPA requested a copy. As a result of today's inspection, a deficiency is being cited pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8. Deficiency is listed on 809-D page. Exit interview was conducted with Administrator. A copy of this report and appeal rights were provided. Signatures on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Jul 10, 2025

Allegation investigated: Licensee did not ensure that facility faucets deliver hot water

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 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.the state’s words, verbatim · CDSS document, Nov 21, 2024 · control 59-AS-20241115130642

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Administrator, Haley Parker, to conduct a case management visit. The purpose of today's visit is to follow up on an Unusual Incident/Injury Report (SIR) that was received by the Department on 11/21/2024. On 11/18/2024, at 7:53 am, staff alerted nurse on shift that back gate alarm was activated and, after conducting a room to room sweep of the Memory Care Unit, staff were unable to locate resident (R1). Staff began searching the surrounding area and were unable to locate R1. At 8:08 am, facility contacted 9-1-1 to file a missing person's report as well as R1's family. R1 was located at city hall at approximately 8:21 am and returned to the facility. R1 was assessed to have no injuries due to incident. R1's LIC 602A dated 11/02/2024 indicates R1 has a diagnosis of dementia. R1's LIC 602A indicates that R1 is unable to leave the facility unassisted with a note saying "facility discretion, was driving before." As a result of today's inspection, a deficiency is being cited pursuant to California Code of Regulations, Title 22, Section 87705(c)(4) regarding care and supervision of residents with dementia. The deficiency is listed on 809-D. 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.the state’s words, verbatim · CDSS document, Nov 21, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(c)(4) · Plan of correction due date: Nov 22, 2024

87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. This requirement is not met as evidenced by: Based on records reviewed, the facility did not ensure that residents R1 was properly supervised, resulting in an AWOL, which poses an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 21, 2024

Plan of correction: Facility will install a secondary alarm to the egress gate in the Memory Care Unit courtyard area. Facility will also conduct a training with staff regarding supervision. Facility will submit training materials and date of training to LPA by POC due date.

Type of visit: Case Management - Other

Licensing Program Analysts (LPAs) Michael Hood and Cassie Mikkelson arrived at the facility and met with Administrator, Haley Parker, to follow-up regarding fire clearance concerns during an annual inspection conducted on 9/11/2024. During today's visit, LPAs conducted a tour of the Memory Care Unit of the facility. LPAs will be requesting that facility add a delayed egress gate to the Memory Care Unit. Facility will follow-up with LPAs regarding expected time frame to install door and status updates. No deficiencies were cited per Title 22 during inspection. Exit interview was conducted with Administrator. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Oct 17, 2024

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Michael Hood and Cassie Mikkelson arrived at the facility unannounced on 9/11/24 to conduct a Required-1 Year Inspection utilizing the inspection tool. LPAs conducted an inspection of the care home to ensure compliance with Title 22 regulations. LPAs observed seven (7) apartments in Assisted Living, four (4) apartments in Memory Care, and two (2) common area bathrooms. LPAs observed apartments to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition, properly maintained, and the hot water temperature was observed to be 117.4 degrees F. LPAs checked the kitchen area for the ability to prepare and store food. Care home has required (2) two-day perishable and (7) seven-day non-perishable food supply on hand. LPAs observed the perimeter of the care home to be free of clutter and debris. LPAs ensured that delayed egress in Memory Care was operational. Smoke detectors are hard wired in the care home and LPAs observed carbon monoxide detectors to be operational in the care home. Fire extinguishers are maintained and ready for emergency use. LPAs reviewed four (4) resident files and four (4) staff files during visit. First aid kit is maintained and ready for emergency use. LPAs checked medication storage and found medication to be locked away and inaccessible to the residents. Facility has a current copy of certificate of liability insurance and LPAs obtained a copy. As a result of this visit, no deficiencies were cited per California Code of Regulations, Title 22. Exit was interview conducted and copy of report given at the conclusion of this visit.the state’s words, verbatim · CDSS document, Sep 11, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Administrator, Haley Parker, to conduct a case management visit. The purpose of today's visit is to follow up on an Unusual Incident/Injury Report (SIR) that was received by the Department on 4/8/2024. On 4/1/2024, staff were alerted by the delayed egress alarm at the back of the facility at approximately 2:20 PM. A head count of the community was completed and it was determined that resident (R1) had left the facility. Staff located the resident outside the facility at the adjacent intersection at approximately 2:28 PM. Resident was then redirected back to the facility by staff. No injuries were observed. Interview with Administrator indicated that the gate alarm of the delayed egress notified staff and staff immediately swept the parameter of the care home. Administrator confirmed that resident was found at the intersection adjacent to the facility and took about 8 minutes from the time in which the gate alarm activated and the resident was located. Administrator stated that another assessment of R1 will be conducted to better represent R1's behaviors. Administrator stated that facility will have staff present in the courtyard area with residents. Administrator will also follow-up with fire department regarding suggestions to improve delayed egress process. LPA observed R1's Physician's Report for RCFE LIC 602A dated 6/4/2023, which states that R1 has a diagnosis of dementia and is not able to leave the facility unassisted. Exit interview was conducted with Administrator. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Apr 16, 2024