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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 475002711
Report Date: 05/24/2021
Date Signed: 05/24/2021 04:30:20 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:SISKIYOU SPRINGS SENIOR LIVING COMMUNITYFACILITY NUMBER:
475002711
ADMINISTRATOR:BRAUER, ELAINEFACILITY TYPE:
740
ADDRESS:351 BRUCE STREETTELEPHONE:
(530) 842-4300
CITY:YREKASTATE: CAZIP CODE:
96097
CAPACITY:85CENSUS: 62DATE:
05/24/2021
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Mike Morris, DirectorTIME COMPLETED:
03:21 PM
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A non-compliance conference was conducted today via Teams, due to COVID-19 and precautionary measures. The purpose of this informal conference meeting was to discuss the most recent complaint and case management conducted that had resulted in 3 Type A and 1 Type B citations, as well as 2 civil penalties. Present in the meeting was Licensing Program Analyst (LPA), DeAnna Williams-Lyons, Licensing Program Manager (LPM) Kevin Mknelly, Regional office Manager (ROM) Alycia Berryman, Administrator Elaine Brauer, Director Mike Morris, Elaine Brauer Executive Director, Shiloh Wood, Vice President of Operations, Cindy Zhang, EPH Representative, and Joel Goldman, Regulatory Counsel. The conference process was explained during this meeting.

Issues discussed during the meeting were:


o Compliance issues at this facility within the last month
o PPE use and training
o Lack of reporting
o Lack of providing requested paperwork in a timely manner
o Staffing issues and training
o Licensee/Administrator accountability

The facility has stated they will do the following to achieve continued and substantial compliance:
· Facility agrees to continue with Calmat until contract ends
· Facility agrees Continue to utilize Temporary Manager Robert Cantoria and complete all recommendations requested
· Facility agrees to continue to hire staff as needed
· Implement all reconditions from the nurses PCC tele-visit with the assistance of Temporary Manager

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 CCLD.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-LyonsTELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2021
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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