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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 475002711
Report Date: 07/02/2021
Date Signed: 07/02/2021 02:05:49 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:JONES, JANETFACILITY TYPE:
740
ADDRESS:351 BRUCE STREETTELEPHONE:
(530) 842-4300
CITY:YREKASTATE: CAZIP CODE:
96097
CAPACITY:85CENSUS: 60DATE:
07/02/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Janet Jones; AdministratorTIME COMPLETED:
02:15 PM
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On 7/2/21 at 11:45 AM, Licensing Program Analyst (LPA) Cheng conducted an unannounced Case Management visit regarding an incident that occurred on 6/20/21. 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: N-95 Masks and gloves Additionally, LPA was screened by front desk personnel.

Incident occurred on 6/20/21 in the facility's memory care unit. LPA was informed that S1 was assisting R3 when he heard a commotion and responded promptly. S1 observed R1 punch R2 on the left ear area. S1 immediately separated R1 from R2 and had R2 directed into R2's room. R2 was assessed and no physical injuries were visible. Both R1 and R2's responsible parties were notified and R2 was monitored for any changes. No injuries occurred and R1 has not had a similar incident since. Facility stated that R1 has and continue to be under close observation as this behavior isn't R1's baseline.

No deficiency observed.

Exit interview conducted and a copy of the report was given.
SUPERVISOR'S NAME: Kevin MknellyTELEPHONE: (209) -81-1925
LICENSING EVALUATOR NAME: Pheej ChengTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2021
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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