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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 475002711
Report Date: 04/29/2022
Date Signed: 05/31/2022 11:34:25 AM


Document Has Been Signed on 05/31/2022 11:34 AM - It Cannot Be Edited

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:HART, ANNETTEFACILITY TYPE:
740
ADDRESS:351 BRUCE STREETTELEPHONE:
(530) 842-4300
CITY:YREKASTATE: CAZIP CODE:
96097
CAPACITY:85CENSUS: DATE:
04/29/2022
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Annette Hart, AdmnisntratorTIME COMPLETED:
04:30 PM
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Office visit regarding a stipulation and waiver and order. Present at the meeting are Mary Sholty, Mike Morris, Teresa Oliveri, Shiloh Woods, Annette Hart, Licensing Program analysts (LPA) Misty Valencia, Licensing Program Manager (LPA) Maribeth Scenty, and Regional Office Manager Alycia Berryman.

Copy of the stipulation and waiver and order was delivered and served to the facility. The stipulation and waiver and order was discussed, to all present in the meeting. Facility acknowledges said document and agrees to abide by the contents set forth in said stipulation and waiver and order.

Licensee shall abide by all terms and conditions set forth in the above referenced stipulation and waiver and order.
Licensee has agreed to provide CCL with the following information as requested in today's meeting:
  • Client Roster
  • Notice of fee increase and monitoring
  • Stipulation has to be posted
  • Increase in facility unannounced health and safety checks every quarter.
  • Reporting in a timely manner-any incident reports, death abuse, facility changes, and any serious injuries.
  • Follow all covid protocols
  • complete infection control plan
  • facility shall not impeded investigations by CCL.

CCL communicated to licensee, that CCL will continue to monitor facility operation, as well as CCL expectation of licensee.

SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Misty ValenciaTELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:
DATE: 04/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2022
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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