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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 475002711
Report Date: 04/12/2024
Date Signed: 07/31/2024 10:29:12 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/28/2023 and conducted by Evaluator Sarah Benson
COMPLAINT CONTROL NUMBER: 59-AS-20231228121456
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: 55DATE:
04/12/2024
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Alex Tayebi AdministratorTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Facility failed to provide supervision to resident resulting in a resident sustaining a fall causing resident to sustain significant injury and hospitalization.

INVESTIGATION FINDINGS:
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On 4-12-24 Sarah Benson Licensing Program Analyst LPA arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 12-28-23. LPA Benson met with Alex Emaude Tayebi Administrator, and explained the purpose of the visit.


During the investigation the Administrator, staff, and clients were interviewed. The Department received the
following documents: Incidnet Reports, Service Request, Facility File review documents, Medical/Ambulance Records, Recent Notes, Certified Death Certificate, Staff Schedule, client and staff list with telephone numbers, employee work schedule.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Sarah BensonTELEPHONE: 530-895-5033
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 59-AS-20231228121456
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 04/12/2024
NARRATIVE
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It was reported that the facility failed to provide supervision to resident resulting in a resident sustaining a fall causing resident to sustain significant injury and hospitalization.

During the investigation process witness statements and facility records reported the resident had been living on the Assisted Living wing and had sustained un-witnessed falls on 09/20/2023 and 10/13/2023. The facility proactively moved resident to the Memory Care wing on 10/20/2023 to provide increased supervision. Medical records corroborated the resident was moved to the Memory Care wing for “enhanced nursing support and a safer environment due to vision loss.” Although the resident was moved to Memory Care, as a preventative fall measure, the resident’s Service Care Plan indicated that the resident had been last assessed a “low” fall risk on 5-3-23 and had not been updated in accordance with the facilities Fall Risk Assessment policy. At the time, the Memory Care wing housed seven residents. Memory Care was staffed with two Resident Assistants (RA) during day shift and one RA at night.



The resident’s hospitalist was interviewed and stated the fall on 10/29/2023 most likely caused the subdural hematoma that was discovered on 11/17/2023 when the resident was sent back to the hospital with increased confusion. However, the physician also stated that it is not uncommon for a brain bleed to not show on initial CT scans after an acute injury and
normal protocol would be to conduct a 24-hr follow-up CT scan before discharging the patient, which was not done in the resident’s case, therefore her physician could not be certain when the injury occurred.

Medical records document the resident was seen by her primary care physician (PCP) on 11/09/2023, as a follow-up to the fall. The resident’s family reported the resident was still having nighttime delusions of people attacking her, but had improved in severity since the initial onset “that led to her fall out of bed.” the family declined to have a temporal arterial
biopsy conducted, as they did not want invasive testing. The resident did not show signs of cardiac compromise or acute distress. The residents PCP offered weekly follow-ups, but family requested bi-weekly follow-ups.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNBUSTANTIATED.


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
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 59-AS-20231228121456
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 04/12/2024
NARRATIVE
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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
LIC9099 (FAS) - (06/04)
Page: 3 of 3