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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 475002711
Report Date: 02/28/2024
Date Signed: 03/01/2024 03:29:48 PM


Document Has Been Signed on 03/01/2024 03:29 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:
02/28/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Dianna Mote Regional DirectorTIME COMPLETED:
10:54 AM
NARRATIVE
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An informal conference was conducted at 10:00am on February 28, 2024, with Sacramento North Regional Office via Microsoft Teams. The purpose of this informal conference meeting is to address the citation issued on February 15, 2024 regarding the facility’s failure to meet the requirements for having a certified administrator. The POC for this citation was due February 21st, 2024. The facility is currently on probation and is required to maintain the facility in strict compliance.
The Administrator was told that this Informal conference is a part of the Administrative Action process and that further noncompliance may result in an elevation to a formal noncompliance conference, which could lead to a referral to the Department's legal division for possible revocation of license.

The following Licensing staff were present:
Licensing Program Analyst (LPA) Sarah Benson and Licensing Program Manager (LPM) Lauren Crocker.

The following facility representatives were present:
Dianna Mote Regional Director of Operations and Mike Morris President

The following topics were covered during today's meeting:
· The need for the facility to have a certified administrator
· Civil penalties
During the meeting Mike Morris stated the facility will have a certified administrator by 3-6-24.
LPA will conduct a follow-up visit to the facility at a future date once corrections have been confirmed.

An exit interview was conducted and a copy of this report will be provided to the facility via email. A copy must be signed and returned to the Department.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Sarah BensonTELEPHONE: 530-895-5033
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2024
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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