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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 475002711
Report Date: 05/19/2021
Date Signed: 05/19/2021 10:06:29 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:
05/19/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:12 AM
MET WITH:TIME COMPLETED:
09:13 AM
NARRATIVE
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On 05/19/2021 at 8:30am Licensing Program Analyst (LPA) Misty Valencia conducted an unannounced on today’s date for the purpose of a Plan of Corrections visit (POC's) that were given on a case management visit on 5/13/2021. The POC's were due to LPA on 5/17/2021 and LPA did not receive the POC's by 5/17/2021. Prior to visit, LPA conducted self-assessment and had no COVID-19 related symptoms. During visit, LPA was wearing an N95 mask, gown and gloves for Covid-19 precautionary measures.

*Civil Penalty assessed* 100.00 a day for 5/18-5/19/2021 for the following POCs that were not completed



87411(f)- Personnel Requirements-Licensee will submit copies and proof of daily check in screening forms daily for the next 14 days
1569.50(3)-Conduct Inimical (3)- Licensee agrees to submit a written statement that all CCL and public health recommendations has been implemented by the 5/17
87405(d)(2)- Administrator - Qualifications and Duties- Licensee shall submit a written plan of correction on how they are going to ensure there is a qualified administrator working for the facility to CCL by the POC date of 5/17/202
872119(a)(2)- Reporting Requirements, Occurrences, such as epidemic outbreak-Licensee will submit a statement of understanding of this requirement along with a statement of the corrective measure taken to ensure timely required reporting by the POC date of 5/17/2021


Exit interview conducted with Administrator Elaine Brauer and reports provided. Appeals rights printed.
SUPERVISOR'S NAME: Kevin MknellyTELEPHONE: (209) -81-1925
LICENSING EVALUATOR NAME: Misty ValenciaTELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2021
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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