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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 475002711
Report Date: 11/16/2022
Date Signed: 11/16/2022 04:02:07 PM


Document Has Been Signed on 11/16/2022 04:02 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 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: 57DATE:
11/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Annette HartTIME COMPLETED:
04:10 PM
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LPA Hiratsuka, conducted this unannounced required annual visit. LPA wore a surgical mask and observed all staff wearing surgical masks.

LPA toured the building with Executive Director Annette Hart. This facility has two floors. LPA inspected several rooms on each floor. The first floor has a memory care unit with seven shared rooms.

Prior to this visit Executive Director notified Community Care Licensing Division (CCLD), that the heating units for four of the seven rooms in the memory care unit of this building stopped working. Four rooms are affected, two residents were temporarily relocated and one has the space heaters. CCLD granted permission to use portable space heaters for one resident room. LPA saw the space heaters and they are safe to touch, turn off automatically if bumped or moved in certain ways, and heat the rooms.

During this visit LPA also checked on the following on top of the regular inspection:
-facility staff training regarding covid protocols, report training, wage and labor training, and elopement training.
-LPA toured the memory care and the delayed egress system works.

Multiple topics were discussed.

No deficiencies cited.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2022
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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