475002711-7-9-2021-25-AS-PCHG-C4RSP6-20210709140237

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 475002711
Report Date: 07/09/2021
Date Signed: 07/09/2021 02:03:27 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:	JONES, JANET		FACILITY TYPE:	740
ADDRESS:	351 BRUCE STREET		TELEPHONE:	(530) 842-4300
CITY:	YREKA	STATE: CA	ZIP CODE:	96097
CAPACITY:	85	CENSUS: 57	DATE:	07/09/2021
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Janet Jones; Administrator		TIME COMPLETED:	02:15 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 7/9/21 at 1 PM, Licensing Program Analyst (LPA) Cheng conducted an unannounced Case Management visit regarding an incident that occurred on 7/3/21. LPA met with Administrator Janet Jones and explained the reason for the visit. 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 Administrator 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: surgical mask and gloves. Additionally, LPA was screened by front desk personnel. On 7/3/21, R1 eloped from the memory care unit (MCU) via north facing door. Facility has a delayed egress system that alarms and delays for 15 secs prior to opening. According to statements obtained, S1 had gone to lunch and S2 did not hear the alarm when it sounded at 5:25 PM as S2 was assisting other resident at the time. S3 entered the MCU and heard the alarm going off. A search team quickly responded and R1 was found across the street at the local hospital within 30 minutes. R1 did not sustain any injuries and is not able to leave the facility unassisted. On 7/9/2021 at 1PM, LPA Cheng along with Administrator Janet Jones tested the door that R1 eloped from and LPA confirms that the alarm is loud enough to be heard from the MCU living room and that there is a 15 second delay. Continuation on LIC 809C.

SUPERVISOR'S NAME: Kevin Mknelly	TELEPHONE: (209) -81-1925
LICENSING EVALUATOR NAME: Pheej Cheng	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021

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: 07/09/2021

NARRATIVE

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On 7/9/21 at 1:30 PM, LPA interviewed S1 - S4.

Facility utilizes a pager system for their MCU exit doors; however, S1 and S2 stated that they did not have pagers on them at the time. Administrator Jones confirmed that the facility has always utilized a paging system for their MCU.

Deficiencies are cited on LIC 809D.

Exit interview conducted and a copy of report along with appeal rights were given.

SUPERVISOR'S NAME: Kevin Mknelly	TELEPHONE: (209) -81-1925
LICENSING EVALUATOR NAME: Pheej Cheng	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021

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: 07/09/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/10/2021 Section Cited	1 2 3 4 5 6 7	87464 Basic Services (f)(1) Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by:
	8 9 10 11 12 13 14	Based on statements and observation, Licensee did provide care and supervision for 1 of 1 resident (R1) which resulted in elopment from facility memory care unit and this poses an immediate health and safety risk to resident in care.	8 9 10 11 12 13 14	Licensee will submit all training materials and signatures of all participants to LPA via e-mail by 7/25/21.
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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 Mknelly	TELEPHONE: (209) -81-1925
LICENSING EVALUATOR NAME: Pheej Cheng	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021

LIC809 (FAS) - (06/04)

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