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Inspection visit

Incident investigation

CASCADES OF GRASS VALLEYLicense 2927005631 citation on this visit
1 citation recorded

Inspector’s narrative

What the inspector wrote

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.

Citations

1 citation recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 87705(c)(4)Type A

    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.

FAQ · About this visit

Common questions about this visit

What happened during the November 21, 2024 inspection of CASCADES OF GRASS VALLEY?

This was a other inspection of CASCADES OF GRASS VALLEY on November 21, 2024. 1 citation were issued: 1 Type A (serious).

Were any citations issued to CASCADES OF GRASS VALLEY on November 21, 2024?

Yes, 1 citation was issued (1 Type A, 0 Type B). The first citation was for: "87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible fo..."

What type of inspection was this?

This was a other inspection. other inspections are conducted by CCLD as part of their licensing oversight.

SourceView on CCLDView original report

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Data from CCLD public records. Last updated . If you believe any information is inaccurate, report it here.