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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 03:27:37 PM


Document Has Been Signed on 03/14/2024 03:27 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:
03:03 PM
MET WITH:Dianna Mote VP of OperationsTIME COMPLETED:
03:45 PM
NARRATIVE
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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)
Page: 1 of 2


Document Has Been Signed on 03/14/2024 03:27 PM - 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: 03/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/28/2024
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 3-28-24.
VP of Operation will notify LPA by email when administrator is hired.
Facility will notify LPA 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: 03/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2024
LIC809 (FAS) - (06/04)
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