475002711-5-7-2021-25-AS-MVAA-C2SVN7-20210507163440

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 475002711
Report Date: 05/07/2021
Date Signed: 05/07/2021 06:13:00 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

FACILITY NAME:	SISKIYOU SPRINGS SENIOR LIVING COMMUNITY		FACILITY NUMBER:	475002711
ADMINISTRATOR:	BRAUER, ELAINE		FACILITY TYPE:	740
ADDRESS:	351 BRUCE STREET		TELEPHONE:	(541) 840-4035
CITY:	YREKA	STATE: CA	ZIP CODE:	96097
CAPACITY:	85	CENSUS:	DATE:	05/07/2021
TYPE OF VISIT:	Office	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Elaine Brauer, Admin		TIME COMPLETED:	03:08 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 5/7/2021 at 1:00p.m. Licensing Program Analyst (LPA) Misty Valencia, Licensing Program Manager (LPM) Kevin Mknelly, Regional office Manager (ROM) Alycia Berryman and Director Of Social Services Stacy Barlow, conducted virtual office meeting with Elaine Brauer (Admin) and Mike Morris CEO. Today’s office meeting was done via Conference call due to COVID-19 precautionary measures. The following individuals attending the conference; -Janet Jones resident care coordinator -Shelly Davis Director of Siskiyou Public health -Tyler Johnson Infection Preventionist for Siskiyou County -Patty Office of emergency services -Jeff Office of emergency services -Myra Cunanan Program Clinical Consultant Supervisor This office meeting was to follow up on a recent visit held 5/04/2021. During today’s virtual office meeting, the following was discussed: · Facility wearing N95 masks while in the facility while there are covid positives · Facility identifying a staffing shortage · Facility providing covid info as soon as possible · Referrals that have been provided CHPCA referral 4/30/21, HAI referral and support, Limited staffing referral

SUPERVISOR'S NAME: Kevin Mknelly	TELEPHONE: (209) -81-1925
LICENSING EVALUATOR NAME: Misty Valencia	TELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: SISKIYOU SPRINGS SENIOR LIVING COMMUNITY	FACILITY NUMBER: 475002711
	VISIT DATE: 05/07/2021

NARRATIVE

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Meeting was concluded by providing the administrator with affirmation that licensing is here for support and admin has agreed to
· Facility staff are to wear N95 masks at all times while in the facility when there are positive residents
· Facility is to follow up on limited term staffing to assist when there is a shortage
· Facility will provide a line list as soon as possible to the LPA.
· Facility will follow up with the following agencies; HAI, AYA, NorthStar

Licensing will follow up on the following
· Follow up with CHPCA referral
· Conduct another PCC
· HAI report
·
Exit interview was conducted, report is provided to Administrator via email due to COVID-19 Precautionary measures. LPA is to send report with a read receipt to ensure delivery.

SUPERVISOR'S NAME: Kevin Mknelly	TELEPHONE: (209) -81-1925
LICENSING EVALUATOR NAME: Misty Valencia	TELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2021

LIC809 (FAS) - (06/04)

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