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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 475002711
Report Date: 06/17/2021
Date Signed: 06/17/2021 01:50:59 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:
06/17/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Administrator Janet JoneTIME COMPLETED:
01:06 PM
NARRATIVE
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On 06/17/2021, at 830am, Licensing Program Analyst (LPA) Misty Valencia conducted an unannounced Case Management visit and met with Administrator Janet Jones. Prior to initiating the visit, 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 Manager and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Masks, gloves, gown, and face shield. Additionally, LPA was screened by front desk personnel.

On 06/17/2021 LPA reviewed R1's medication records from 06/09-06/14/2021. The investigation revealed the following: R1 did not receive medication Lovenox that was prescribed on 06/09/2021 from Fairchild Medical Center (FMC). The facility failed to provide R1 with prescribed Levonox, 06/09-06/15, 2021, a total of 8 days of missed doses. Interviews with responsible personnel to include two (2) Medication Technicians, Administrator Janet Jones all confirmed R1 did not receive the prescribed medication because it is not a authorized medication that the facility should administer. Interviews confirmed the facility failed to obtain R1's medication, which resulted in the missed doses.

Based on the evidence obtained, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, (Title 22), is being cited on the attached LIC 9099D.

Plan of correction (POC) were discussed. Appeal rights were provided and exit interview conducted
SUPERVISOR'S NAME: Kevin MknellyTELEPHONE: (209) -81-1925
LICENSING EVALUATOR NAME: Misty ValenciaTELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/25/2021
Section Cited

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Incidental Medical and Dental Care Services. The licensee shall assist residents with self-administered medications when needed**This requirement is not met as evidenced by
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Based on LPAs interview and record review the facility failed to ensure R1's medications were not adminstered as prescribed. This poses an immediate health and safety risk to clients in care
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 ***Amended***

Training will include roster with staff signatures will be faxed or emailed to LPA no later than 06/25/2021

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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: 06/25/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/25/2021
LIC809 (FAS) - (06/04)
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