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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 475002711
Report Date: 10/27/2021
Date Signed: 10/27/2021 10:59:35 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:JONES, JANETFACILITY TYPE:
740
ADDRESS:351 BRUCE STREETTELEPHONE:
(530) 842-4300
CITY:YREKASTATE: CAZIP CODE:
96097
CAPACITY:85CENSUS: 62DATE:
10/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Janet Jones, AdminTIME COMPLETED:
11:00 AM
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On 10/27/2021 Licensing Program Analysts (LPA) Misty Valencia arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the infection control domain, LPA met with Janet Jones, Administrator and explained the purpose of the visit. Prior to initiating the annual inspection, 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 licensee 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: N95 Mask. Additional LPA was screen at the front desk by office staff Carrie Eppler.

LPA Valencia and Jones toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, five (5) resident bedrooms, two (2) bathrooms, kitchen, storage areas, and common outside patio. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA Valencia and the Admin completed the infection control domain and facility was found to be in substantial compliance at this time.



No deficiencies are being cited as a result of todays inspection.

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

DATE: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021
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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