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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 475002711
Report Date: 03/14/2024
Date Signed: 03/14/2024 02:51:47 PM


Document Has Been Signed on 03/14/2024 02:51 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: 54DATE:
03/14/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Dianna Mote VP of OperationTIME COMPLETED:
03:16 PM
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On 3-14-24 Licensing Program Analyst LPA Sarah Benson arrived at the facility and met with Dianna Mote VP of Operation to clear POC dated 2-15-24 concerning Administrator on site.

During the office meeting held on 2-15-24 Mike Morris stated the facility will have a certified administrator by 3-6-24. On 3-6-24 Dianna Mote VP of Operation requested an extension to 3-13-24 to clear POC. During LPA Benson's visit on 3-14-24 no administrator is on site. The last day of previous Administrator was 2-8-24.

The following deficiencies were observed (See LIC 809D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. Civil Penalties will be on going until POC is cleared.

Exit interview conducted, a copy of the report, LIC421FC and appeal rights provided to VP of Operation Dianna Mote.




SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Sarah BensonTELEPHONE: 530-895-5033
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2024
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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