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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 475002711
Report Date: 06/25/2024
Date Signed: 06/27/2024 03:56:48 PM

Substantiated


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: 52DATE:
06/25/2024
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Hailey Gibson Care CoordinatorTIME COMPLETED:
03:50 PM
ALLEGATION(S):
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Facility failed to report incidents to CCL.
INVESTIGATION FINDINGS:
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During the investigation process it was discovered the facility had incident reports of multiple falls dated 09/20/2023, 10/13/2023, 10/16/23 and 10/29/2023 for residents. When Community Care licensing staff reviewed incident reports that were submitted by the facility, only one incident was reported for residents in October and November 2023. This incident was reported as: On 10-16-23 staff recorded an incident report that resident 1 had a hospital visit for un-witnessed fall, resident was found on the floor and complained of hip pain. While reviewing the facilitycare notes it was discovered 4 residents had hospital or ER visits with no incident report received by CCLD. During interviewing staff it was reported that all incident reports are faxed to CCLD. Document review revealed CCLD has 1 incident report on file for 1 resident for the months of 10-23 and 11-23.

continued on 9099-D
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Sarah BensonTELEPHONE: 530-895-5033
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2024
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 2
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/25/2024
Section Cited
CCR
87211(a)(1)
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Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: A written report shall be submitted within seven days of occurrence...This requirement was not met as evidenced by:
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Staff will report all incidnet reports.
In the future the facility will keep fax receipts of any incident reports that are submitted to CCLD.
Training for all staff working with incident reports.
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While reviewing the facility Care Notes, it was discovered 4 residents had hospital or ER visits in the months of October and November 2023 with only one incident report received by CCLD.
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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: 06/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2024
LIC9099 (FAS) - (06/04)
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