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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 475002711
Report Date: 02/15/2024
Date Signed: 02/15/2024 11:29:30 AM


Document Has Been Signed on 02/15/2024 11:29 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, 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: 54DATE:
02/15/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
09:24 AM
MET WITH:Carey Eppler Bussiness Office ManagerTIME COMPLETED:
11:45 AM
NARRATIVE
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On 2-15-24 Sarah Benson Licensing Program Analyst (LPA) met with Carey Eppler Bussiness Office Manager to conducted this unannounced probation visit as directed by the Stipulation and Wavier; and Order; dated February 25, 2022.

LPA toured the facility including but not limited to: memory care, kitchen, hallways and common areas.
LPA reviewed the Stipulation and Waiver; and Order, regarding COVID protocols. 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These protocols shall be followed until the facility receives notice from the Department that COVID protocols have been rescinded." These orders have been rescinded due to the State of Emergency being declared over per Provider Information Notices (PIN) PIN 23-04-CCLD, and PIN 23-07-ASC.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. The administrator has set up monthly meetings with the county infection control specials for Siskiyou county health department to train and inform staff of infection control protocol.

During the visit and a phone call with Dianna Mote Regional VP Operations, it was discovered the facility has no administrator.
The following deficiencies were observed (See LIC 809D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted, a copy of the report, and appeal rights provided to Carey Eppler.

SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Sarah BensonTELEPHONE: 530-895-5033
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2024
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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Document Has Been Signed on 02/15/2024 11:29 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 02/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/16/2024
Section Cited
CCR
87405(a)

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All facilities shall have a qualified and currently certified administrator... The administrator... shall be on the premises a sufficient number of hours to permit adequate attention...
This requirement was not met as evidenced by:
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Facility will appoint a certified administrator by 2-21-24.
Facility will notify LPA by phone or email with new administrators information.
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Through observation, interviews and investigation the LPA Benson discovered the facility has no Administrator at this time. The previous adminstrators last day was 2-8-24.
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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: 02/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2024
LIC809 (FAS) - (06/04)
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