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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 475002711
Report Date: 04/12/2024
Date Signed: 04/12/2024 02:46:18 PM


Document Has Been Signed on 04/12/2024 02:46 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:TAYEBI, EMAUDEFACILITY TYPE:
740
ADDRESS:351 BRUCE STREETTELEPHONE:
(530) 842-4300
CITY:YREKASTATE: CAZIP CODE:
96097
CAPACITY:85CENSUS: 55DATE:
04/12/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Alex Tayebi AdministratorTIME COMPLETED:
02:55 PM
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On 2-14-24 Licensing Program Analyst LPA Sarah Benson arrived at the facility and met with Alex Tayebi Executive Director to clear POC dated 2-15-24 concerning Administrator on site and share complaint findings. LPA Benson and Alex Tayebi Executive Director toured the facility together to ensure the health and safety of residents in care.

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.

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. Dianna Mote VP requested an extension to have administrator on site to 3-28-24.

On 4-12-24 LPA Benson interviewed Alex Tayebi to verify 3-28-24 was his first day as administrator at Siskiyou Springs.




Exit interview conducted, a copy of the report, LIC421FC and appeal rights provided to Alex Tayebi Executive Director.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Sarah BensonTELEPHONE: 530-895-5033
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2024
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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