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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 475002711
Report Date: 06/12/2021
Date Signed: 06/12/2021 11:13:58 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: DATE:
06/12/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Facility Manager Barbara WilliamsTIME COMPLETED:
12:30 PM
NARRATIVE
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On 06/12/2021 11:30AM, Licensing Program Analyst (LPA) Misty Valencia and accompanied by Investigation bureau Investigator (IBI) conducted an unannounced Case Management visit and met with Facility Manager Barbara William. Prior to initiating the visit, LPA and IBI 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 TM 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.

The purpose of this inspection was to cite for deficiencies found on June 11, 2021 during the departments ongoing investigation for complaint number 25-AS-20210514175905.

Based on observations and statements it was found that on June 11, 2021 while the Department was attempting to hold a private interview with a staff member, Administrator S1 interrupted the interview while it was in progress to inquire about the interviews and required the employee report the content of the interview to them after the interview was concluded.

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

DATE: 06/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2021
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 3
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: 06/12/2021
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Furthermore, the department’s investigation to date, based on staff interviews, that S1 has repeatedly discouraged employees from cooperating with the Department’s investigation and threatened employees with termination if their cooperation is found out by her.

As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.

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

DATE: 06/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: 06/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
06/13/2021
Section Cited

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Whistleblowers; retaliation-No licensee, or officer …shall … retaliate in any manner, including, but not limited to, … against any employee of the licensee’s facility, on the basis, or for the reason that,… initiated or......
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This requirement was not met as evidenced by statements to the department’s investigator of threats of retaliation for staff cooperating with an investigation. This poses an immediate risk to the health and safety of residents in care.
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A statement from the facility Manager regarding these measures will be submitted to CCL by the POC date of 6/13/21.
Request Denied
Type A
06/13/2021
Section Cited

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Inspection Authority of the Licensing Agency- (b)The licensee shall ensure that provisions are made for private interviews with any resident or any staff member… This requirement was not met
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As evidenced by the Administrator’s interruption of, and discouragement of cooperation with, The Department interviewing of staff. This posed an immediate risk to the health and safety
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A statement from the licensee regarding these measures will be submitted to CCL by the POC date of 6/13/21.
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: 06/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2021
LIC809 (FAS) - (06/04)
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