<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 475002711
Report Date: 09/29/2021
Date Signed: 09/29/2021 04:19:52 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: DATE:
09/29/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Janet Jones, AdministratorTIME COMPLETED:
05:00 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 9/29/21, Licensing Program Analyst (LPA) Misty Valencia conducted an unannounced Case Management Health and Safety visit as directed by the department. 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 masks. Additionally, LPA was screened by front desk personnel.

LPA toured the facility inside and out including but not limited to facility dining areas, outside areas, staff break rooms, kitchen area, and memory care unit (MCU). LPA observed that the facility has all proper and required signs for COVID-19 prevention and safety protocol. LPA observed that all sinks had hand washing signs posted. LPA observed all staff members to be wearing surgical masks. All staff and visitors are screened upon entrance and leaving the facility. LPA observed hand sanitizers throughout the facility. LPA reviewed facility's employee screening log and observed no issues. LPA observed multiple residents walking around in surgical masks, having social time while social distancing and seemed to be happy. Administrator reports that they have hired six (6) new staff members that are currently one on the floor, a driver who shadowed today, two (2) people in relias training, as well as two (2) waiting to be on board.

No deficiencies observed.

Exit interview conducted and a copy of report was emailed.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Misty ValenciaTELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021
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 1