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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002787
Report Date: 08/02/2022
Date Signed: 08/02/2022 01:46:39 PM


Document Has Been Signed on 08/02/2022 01:46 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 08/02/2022 01:43 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

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***AMENDED***
This report was amended due to no signatur showing up.
ON 08/02/2022 Licensing Program Analysts (LPAs) Misty Valencia and Shannon Dieagoruelas arrived at the facility to conduct an announced health and safety visit and met Kristine Boban, Administrator Prior to visits 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; contacted licensee and completed a facility risk assessment. LPAs ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Mask, gown, gloves. Additionally, LPAs were screened by facility staff.

On July 30, 2022, the Sacramento Regional Office was notified of a mandatory evacuation order in Siskiyou County due to the McKinney Fire. The fire is reported to have burned 55,493 Acres and is 0% contained. Siskiyou Springs Senior Living Community evacuated all 60 residents: Residents were relocated to a sister facility in Redding, two (2) facilities in Ashland Oregon, one (1) in a SNF and the remaining residents are currently staying with family. Admin also stated that the thirteen (13) residents that was relocated to facility had their medications with them, as well as care plans. LPA was informed that residents needs are being taken care of and staffing levels were increased. LPAs toured facility and All residents interviewed reported that they are receiving everything they need and love the food. Food supply is adequate to accommodate the extra residents, the dining room is large enough to accommodate the extra residents.

Admin also understands that all incidents regarding any residents currently at the facility need to be sent to Community Care Licensing (CCL) as the usually would be reported. No deficiencies are being cited today. Exit interview conducted and copy of report left at the facility
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Misty ValenciaTELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2022
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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