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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 475002711
Report Date: 06/25/2021
Date Signed: 06/25/2021 10:45:47 AM

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: 61DATE:
06/25/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator Janet JonesTIME COMPLETED:
11:00 AM
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On 06/25/2021, Licensing Program Analyst (LPA) Misty Valencia conducted an unannounced Case Management visit regarding in incident report Community Care Licensing (CCL) received on 06/15/2021, 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 Mask. Additionally, LPA was screened by front desk personnel.

Incident report received stated that C1 received an additional dose of Hydrocodone (Hydro) 5/325mg medication on 06/15/2021 by a PM medication technician (med tech). The AM med tech noticed it while conducting a narcotic counts The facility does medications counts each shift and the error was caught the same day. The Primary Care Physician (PCP) notified and family was notified.

LPA and administrator discussed the outcome of C1 given an additional dose of medication and administrator stated C1 suffered no ill effects and has been functioning as expected. Administrator further stated that staff will be disciplined and a training was conducted on Tuesday June 22, 2021.

At this point it appears that the facility reacted immediately and appropriately to the error, reported appropriately, monitored the client, and all staff is receiving further training. No deficiencies are being cited at this time.

Exit interview conducted, copy of report left at the facility.
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 licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021
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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