475002711-5-14-2021-25-AS-MVAA-C2ZVP8-20210514163619

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 475002711
Report Date: 05/05/2021
Date Signed: 05/14/2021 04:36:24 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: 64	DATE:	05/05/2021
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	05:25 PM
MET WITH:	Elaine Brauer		TIME COMPLETED:	05:26 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 5/4/21, from 9-1015am LPA Misty Valencia, conducted an in person PCC health and safety check visit due to Covid outbreak and met with Administrator Elaine Brauer. ROM Alycia Berryman, LPM Kevin McNelly, along with CCL Nurse Cristina Wong were included virtually via teams. The advice topics covered are: More signage- Infection control, distancing and hand washing at entrances, in break rooms, bathrooms, at sinks Don and Doff signs at Covid pos rooms- Don outside the room, doff inside In the break room, kitchen and med room- distancing and disinfecting signs Develop more strategies to distance, especially memory care, residents and attempt to cohort known positives. Any chance to have more activities then TV? How about making dining area and additional TV/ entertainment area to break up the crowd? Continue to try to train, encourage, incentivize, remind mask use of residents. Try many colors and styles.

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

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2021

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: 05/05/2021

NARRATIVE

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Have the conversation with both families of the +/- shared rooms to see what is possible to minimize exposure. Can one of them go home for 10-14 days?

Greater emphasis on staff changing PPE between infected/ non infected areas.

Gloves should be changed A LOT.

Paper towels at all hand washing sites.

Covid positive rooms closed when possible.

1015-1145 am Infection Preventionist Kristy Trausch arrived and also concluded a meeting with LPA Valencia, Shelly Davis Director of Shasta County Public Health, Dr Studs, Dr with Shasta County Prevention Control, and Tyler Johnson, Siskiyou Infection Prevention for an infection control meeting for recommendations and questions the facility had regarding Covid-19.

Following items were included in the meeting
-Cleaning supplies and making sure they were up to EPA Standards
-Staff back up plan in case of outbreak
-Resident checks and to look for any signs/symptoms of Covid
-PPE supplies
-Visitation plans
-Testing for Covid and meeting state surveillance requirements
-Activities and the need for continuing social distancing

HAI Trausch asked Admin if she needed assistance with anything. Admin reported “honestly nothing. I am ok and will reach out if I need anything” Admin was thankful for the support and will reach out if she needs anything.

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

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2021

LIC809 (FAS) - (06/04)

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