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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 475002711
Report Date: 11/06/2023
Date Signed: 11/09/2023 01:59:42 PM


Document Has Been Signed on 11/09/2023 01:59 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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:
11/06/2023
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Mike Morris CEOTIME COMPLETED:
11:00 AM
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11-06-23 at 10:00AM Pam Gill, Assistant Program Administrator conducted an office meeting with the following individuals Alycia Berryman, Regional Manager Sacramento North, Carla Nuti-Martinez, Regional Manager Santa Rosa, Christopher Arnhold, Licensing Program Analyst, Sarah Benson, Licensing Program Analyst, Joel Goldman, Attorney, Shawn Metcalf, Director, Lisa Lenderman, In House Council, Sean Wignall, Portfolio Manager, Chuck Murphy, Finance Attorney, Robert Sahyan, Attorney and Mike Morris, CEO Lenity. The meeting was held using Microsoft Teams.

The meeting was held to discuss the possible financial concerns with the facility. RO requested updated lease agreements and staffing updates related to vacancies.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Sarah BensonTELEPHONE: 530-895-5033
LICENSING EVALUATOR SIGNATURE:
DATE: 11/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2023
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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