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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 475002711
Report Date: 12/06/2023
Date Signed: 12/06/2023 02:27:59 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/14/2023 and conducted by Evaluator Sarah Benson
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20230814145323
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: 54DATE:
12/06/2023
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Annette Hart Executive DirectorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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The administrator raises her voice in front of the residents.
INVESTIGATION FINDINGS:
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On 12-06-23, 1:30PM Sarah Benson, Licensing Program Analyst (LPA) arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 08/23/23. LPA Benson met with Annette Hart, Executive Director, and explained the purpose of the visit.

The administrator raises her voice in front of residents.
During the interview process, 10 staff persons and four residents were interviewed. The following documents were received and reviewed: Client and staff list with telephone numbers, employee work schedule, shower list, refusal logs and observation logs.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Sarah BensonTELEPHONE: 530-895-5033
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 59-AS-20230814145323
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 COMMUNITY
FACILITY NUMBER: 475002711
VISIT DATE: 12/06/2023
NARRATIVE
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During the investigation process, most of the persons interviewed, indicated that the administrator does raise her voice and has reprimanded the staff persons in front of the residents. This is a personal rights violation, and the licensee will be cited.

Based on investigation observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D.

Appeal Rights were explained and provided to the facility representative listed above and an exit interview was conducted. If any of the cited deficiencies are not corrected by the noted due date, civil penalties may be assessed.

SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Sarah BensonTELEPHONE: 530-895-5033
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 59-AS-20230814145323
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 COMMUNITY
FACILITY NUMBER: 475002711
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/16/2023
Section Cited
CCR
87468.1(a)(1)
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 Personal Rights of Residents in All Facilities - Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff...This requirement was not met as evidenced by:
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The administrator agrees to submit to the licensing agency a statement of how this type of deficiency will be avoided in the future. In addition, the administrator shall outline to the staff persons how she will conduct herself in the future.
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Based on interviews of staff persons and residents, the licensee did not ensure that the residents were accorded with dignity in their personal relationships, which posses a poential health risk to residents in care.
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Administrator will submit all documents to LPA via e-mail by 12-16-23.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Sarah BensonTELEPHONE: 530-895-5033
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/14/2023 and conducted by Evaluator Sarah Benson
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20230814145323

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: 54DATE:
12/06/2023
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Annette Hart Executive DirectorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility is understaffed.
Staff are not ensuring that residents are receiving their showers.
Residents are required to attend activities.
INVESTIGATION FINDINGS:
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On 12-06-23, 1:30PM Sarah Benson, Licensing Program Analyst (LPA) arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 08/23/23. LPA Benson met with Annette Hart, Executive Director, and explained the purpose of the visit.


During the interview process, 10 staff persons and four residents were interviewed. The following documents were received and reviewed: Client and staff list with telephone numbers, employee work schedule, shower list, refusal logs and observation logs.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Sarah BensonTELEPHONE: 530-895-5033
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 59-AS-20230814145323
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 COMMUNITY
FACILITY NUMBER: 475002711
VISIT DATE: 12/06/2023
NARRATIVE
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Facility is understaffed.

During the investigation process, it was reported by several staff persons that the facility is understaffed in that the needs of the residents are not being met in a timely manner due to various concerns. However, overall, it was reported for the most part that resident needs were being met.

Staff are not ensuring that residents are receiving their showers.

During the interview process, 10 staff persons and four residents were interviewed. The following documents were received and reviewed: Client and staff list with telephone numbers, employee work schedule, shower list, refusal logs and observation logs.

During the investigation process, staff indicated that for the most part, the residents are given showers twice a week and that staff are recording it. Three residents indicated that they felt that they get their showers regularly and one resident stated that she wasn’t sure.

During an interview with Resident Care Coordinator (RCC), it was reported that showers are offered twice a week with a record kept of residents who refuse showers. The RCC stated that when a resident refuses to shower three times, staff will ask if they would like to change the shower time, or may change staff who are assisting, and the last resort will be to get the family involved.

The administrator stated shower records are kept, and recorded on a refusal log when a resident refuses. Administrator reported the care plan for showering is twice a week.

While reviewing the resident shower list and shower refusal logs, it is recorded that 6 of 7 residents shower twice a week. One resident prefers to shower once a week.

Residents are required to attend activities.

During the interview process, 10 staff persons and four residents were interviewed. The following documents were received and reviewed: Client and staff list with telephone numbers, employee work schedule, shower list, refusal logs, observation logs and activity calendar.

During the investigation process, it was reported by all staff persons and residents that activities are offered to the residents; however, at times, the residents refuse to participate. Staff indicated that residents have the right to refuse participation and are not required to attend activities.

Although the above allegations mentioned may have happened, or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are Unsubstantiated.

SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Sarah BensonTELEPHONE: 530-895-5033
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5