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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 475002711
Report Date: 05/13/2021
Date Signed: 05/15/2021 01:20:41 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 COMMUNITYFACILITY NUMBER:
475002711
ADMINISTRATOR:BRAUER, ELAINEFACILITY TYPE:
740
ADDRESS:351 BRUCE STREETTELEPHONE:
(530) 842-4300
CITY:YREKASTATE: CAZIP CODE:
96097
CAPACITY:85CENSUS: 62DATE:
05/13/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Elaine Brauer, AdministratorTIME COMPLETED:
05:00 PM
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On 5/13/2020, Licensing Program Analyst (LPA) Misty Valencia called via-telephone and conducted an announced case management visit and met with Elaine Brauer Administrator. The purpose of this visit is issue citations for violations that occurred during the course of the current Covid 19 outbreak.

On 4/27/2021, California Department of Social Services (CDSS) Community Care Licensing (CCL) received information that on 4/19/2021, a caregiver (S1), worked while symptomatic. In interviews it was found that S1 did so after Administrator Elaine Brauer noticed that S1’s was not looking herself. S1 called in sick for the morning portion of their shift on 4/20/21 reported that S1 was not feeling good. S1 was allowed to work for the latter half of their shift on 4/20/21. S1 continued to work with symptoms but requested to leave early due to not feeling well. S1 called in 4/22/21 reporting that S1 was not feeling well and needed to get some rest. On 4/23/21 S1 reported to work reporting that S1 was feeling better. 4/24/21 S1 called the facility and reported going into the emergency room because S1 was not getting any better and believes S1 may have strep throat. Interviews conducted with the administrator and the resident care coordinator it was found that at no point during the period of 4/19/21 to 4/24/21, did the Administrator nor the Resident Care Coordinator follow up with S1 regarding S1’s symptoms or the potential hazard these symptoms posed to residents in care. The facility or its management did not assess if the symptoms were a significant threat to the well-being of residents or determine if S1 should have been sent home as a result of S1’s symptoms.

SUPERVISOR'S NAME: Kevin MknellyTELEPHONE: (209) -81-1925
LICENSING EVALUATOR NAME: Misty ValenciaTELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 5
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: 05/13/2021
NARRATIVE
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On 04/24/2021 the facility received a confirmed Covid-19 test result for S1, who was seen at the ER on 4/24/2021 for covid like symptoms. The Administrator notified LPA Valencia by voicemail on 4/26/2021 instead of reporting to the CCL office. LPA received the phone voice message 4/27/2021, as LPA’s regular day off was 4/26/2021.

Community Care Licensing (CCL), Siskiyou Public Health (SPH) and California Department of Public Health (CDPH) completed in person and web based tele-communication consultation visits to the facility on 5/5/2021 and virtually on 5/10/2021.

During the 5/5/2021 in person visit, the licensee was advised by CCL of the following, included but not limited to:


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, such as additional activities using available space differently;
Train, encourage, incentivize, remind mask use of memory care residents as much as would be tolerated;
Have the conversation with both families of the +/- shared rooms to see what is possible to minimize exposure;
Greater emphasis on staff changing PPE between infected/ non infected areas; and,
Gloves used and changed appropriately to infection control guidelines.

During the 5/10/2021 in virtual visit, the licensee was advised by CCL of the following, included but not limited to:
Reminders to have following throughout facility- Paper towels at all hand washing sites and Covid positive rooms closed when possible;
Facility staff are to wear N95 masks while in the facility while there are covid positives;
Facility identifying a staffing shortage in their reports to CCL- specifically providing staff schedules;


SUPERVISOR'S NAME: Kevin MknellyTELEPHONE: (209) -81-1925
LICENSING EVALUATOR NAME: Misty ValenciaTELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2021
LIC809 (FAS) - (06/04)
Page: 2 of 5
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: 05/13/2021
NARRATIVE
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Facility providing Covid-19 line lists information to CCL as required and requested for all new cases and for ongoing surveillance testing;

Administrator to follow through on referral and resources available to them from various agencies. The Administrator agreed during this meeting to immediately follow up on the referrals for staffing assistance, infection control assistance, mitigation plan revisions and possible financial assistance as needed.

As a result of events that transpired during the course of this Covid-19 outbreak response, it was found that significant non-compliance has occurred for personnel requirements, the conduct of the Administrator, the Administrator fulfilling their duties and in reporting requirements.

Deficiencies are cited per California Code of Regulations, Title 22, and listed on LIC 809D. Failure to submit Proof of Corrections (POC's) by Plan of Correction date may result in civil penalties.

Exit interview was conducted, report is provided to Administrator via email due to COVID-19 Precautionary measures.

SUPERVISOR'S NAME: Kevin MknellyTELEPHONE: (209) -81-1925
LICENSING EVALUATOR NAME: Misty ValenciaTELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2021
LIC809 (FAS) - (06/04)
Page: 3 of 5
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/17/2021
Section Cited

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Personnel Requirements- Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.This requirement is not met as evidenced by;
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Based on staff interviews the Adminitrator failed to prevent staff who had evidence of physical illness from tending to residents in care which poses an immediate health and safety risk to residents in care
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Licensee will submit copies and proof of daily check in screening forms daily for the next 14 days
Request Denied
Type A
05/17/2021
Section Cited

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Conduct Inimical (3) Conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility or the people of the State of California.This requirement is not met as evidenced by:
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 Based on staff interviews record and LPA observation, the Administrator failed to assess staff with an to the illness which poses an immediate health and safety risk to residents in care.
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Licensee agrees to submit a written statement that all CCL and public health recommendations has been implemented by the 5/17
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Kevin MknellyTELEPHONE: (209) -81-1925
LICENSING EVALUATOR NAME: Misty ValenciaTELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:
DATE: 05/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2021
LIC809 (FAS) - (06/04)
Page: 4 of 5
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/17/2021
Section Cited

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Administrator - Qualifications and Duties The administrator shall have the qualifications … (2) Knowledge of and ability to conform to the applicable lregulations This requirement was not met as evidenced by:
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Admin did not enforce adequate staff screening, quarantine, report as required, did not implement recommended measures from nurse visits, which poses an immediate health and safety risk to residents in care.
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Request Denied
Type B
05/17/2021
Section Cited

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Reporting Requirements, Occurrences, such as epidemic outbreaks...which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile
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This requirement is not met as evidenced by: The Administrator notified LPA Valencia by voicemail on 4/26/2021 instead of reporting to the CCL office, which poses an immediate health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Kevin MknellyTELEPHONE: (209) -81-1925
LICENSING EVALUATOR NAME: Misty ValenciaTELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:
DATE: 05/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2021
LIC809 (FAS) - (06/04)
Page: 5 of 5