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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 475002711
Report Date: 08/25/2021
Date Signed: 08/25/2021 01:15:31 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: 62DATE:
08/25/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator Janet JonesTIME COMPLETED:
01:00 PM
NARRATIVE
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On 08/25/2021, Licensing Program Analysts (LPAs) Misty Valencia and Dawn Keane 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: N95 masks, gloves and gowns. Additionally, LPAs was screened by front desk personnel Carey Eppler.

LPAs 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. LPAs observed that all sinks had hand washing signs posted. LPAs observed all staff members to be wearing surgical masks. LPA explained that all staff are mandated to wear a N95 mask at this time, due to covid19 exposure. Administrator immediately got on her walkie talkie and informed all staff to put on a N95 mask. Administrator reported that LPHD recommended surgical mask be worn and not N-95. LPA explained that facility needs to meet the most stringent requirement as to satisfy all requirements, 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.

Deficiencies are cited on LIC 809D.

Exit interview conducted and a copy of report along with appeal rights were given.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Misty ValenciaTELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021
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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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: 08/25/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
08/27/2021
Section Cited

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Personal Rights of Residents in All care Facilities... To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.This requirement is not met as evidenced by
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Based on LPA's visit and observations staff were not wearing N95 masks and have had exposure in the facility by a staff member. This posed an immediate risk to the residents in care.
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Licensee will submit their plan for developing/training of such standards and include that training will be completed and proof submitted by 08/27/2021.

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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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Misty ValenciaTELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:
DATE: 08/25/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2021
LIC809 (FAS) - (06/04)
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