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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 475002711
Report Date: 05/16/2023
Date Signed: 05/16/2023 11:01:13 AM


Document Has Been Signed on 05/16/2023 11:01 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
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



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:
05/16/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Annette HartTIME COMPLETED:
11:10 AM
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LPA Hiratsuka, conducted this unannounced case management visit as directed by the Stipulation and Wavier; and Order; dated February 25, 2022.

LPA toured the facility including but not limited to: resident apartments and common areas.

LPA reviewed the Stipulation and Waiver; and Order, regarding COVID protocols with Administrator Annette Hart. Per the Stipulation and Waiver; and Order, section F states, "Respondents shall take reasonable steps to inform direct care employees how to follow applicable current COVID protocols. These protocols shall be followed until the facility receives notice from the Department that COVID protocols have been rescinded." These orders have been rescinded due to the State of Emergency being declared over per Provider Information Notices (PIN) PIN 23-04-CCLD, and PIN 23-07-ASC. The mandates ended April 3, 2023. The PINS may be found on https://www.cdss.ca.gov/inforesources/community-care-licensing/policy/provider-information-notices/adult-senior-care

The facility shall follow all Local and State COVID protocols; whichever is stricter. The facility shall also follow all Local and State COVID protocols upon learning of a possible exposure and/or positive COVID cases.

Several other topics were discussed.

No deficiencies cited.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2023
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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