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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 475002711
Report Date: 06/16/2022
Date Signed: 06/16/2022 09:33:20 AM


Document Has Been Signed on 06/16/2022 09:33 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: 58DATE:
06/16/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Annette Hart, AdminTIME COMPLETED:
10:00 AM
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On 06/16/2022, Licensing Program Analyst (LPA) Misty Valencia conducted an unannounced Case Management Health and Safety visit as directed by the department. LPA met with Administrator Annette Hart 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: N-95 mask. Additionally, LPA was screened by front desk personnel.

Facility is currently on lock down. Not allowing visitors, dinning and activities are closed due to current covid positives. LPA toured the facility inside and out including but not limited to facility dining areas, and outside areas. 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 N95 masks. All staff are screened upon entrance and leaving the facility. LPA observed hand sanitizers throughout the facility. LPA observed all residents to be in their rooms where they provided their meals and medications. LPA observed one resident who is currently testing positive with PPE cart, trash can, PPE donning/Doffing sign, stop sign, and hourly observation log outside the door. Facility was being cleaned by staff member while LPA was touring.

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: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2022
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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