475002711-5-27-2021-25-AS-PCHG-C3EUWS-20210527155713

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 475002711
Report Date: 05/27/2021
Date Signed: 05/27/2021 03:58:26 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 COMMUNITY		FACILITY NUMBER:	475002711
ADMINISTRATOR:	BRAUER, ELAINE		FACILITY TYPE:	740
ADDRESS:	351 BRUCE STREET		TELEPHONE:	(530) 842-4300
CITY:	YREKA	STATE: CA	ZIP CODE:	96097
CAPACITY:	85	CENSUS: 62	DATE:	05/27/2021
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Elaine Brauer; Administrator		TIME COMPLETED:	04:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 5/27/21 at 11:45 AM, Licensing Program Analyst (LPA) Cheng conducted an unannounced Case Management Health and Safety visit as directed by the department. LPA met with Administrator Elaine Brauer and explained the reason for the visit. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted Administrator and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Masks, gloves, gown, and face shield. Additionally, LPA was screened by front desk personnel. LPA toured the facility inside and out including but not limited to facility dining areas, outside areas, staff break rooms, kitchen area, and memory care unit (MCU). LPA observed that all clients are currently quarantined in their rooms. LPA observed that the facility was clean and free of any obstruction of pathways. Facility has a 7-day non-perishable and 2-day perishable supply of food. LPA observed that the facility has all proper and required signs for COVID-19 prevention and safety protocol. LPA observed that all sinks had hand washing signs posted. LPA observed that a doffing and dawning signage was posted out in front of the memory care unit along with Personal Protection Equipment (PPE) for staff to put on prior to entering. LPA observed all MCU staff to be fully dressed in PPE and utilizing an N95 mask along with a face shield. All other staff not working in the MCU were wearing a surgical mask and some with face shields. Continuation on LIC 809C.

SUPERVISOR'S NAME: Kevin Mknelly	TELEPHONE: (209) -81-1925
LICENSING EVALUATOR NAME: Pheej Cheng	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 COMMUNITY	FACILITY NUMBER: 475002711
	VISIT DATE: 05/27/2021

NARRATIVE

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LPA observed that all PPE supplies were centrally stored in the Assisted Living portion of the facility in Unit #106. Facility has sufficient supplies of PPE on hand. LPA observed facility's break room. Prior to entrance, the break room door has a sign stating that only two employees are allowed at one time. Administrator Brauer stated that staff breaks are coordinated to only allow two staffs to be on break at one time. LPA observed that facility is checking residents at least four times a day and keeps a log of it. Some resident's require hourly checks and facility has a covered check-in log on the outside of the resident's room. LPA observed that there are 18 staff members working: 3 in MCU, 5 in Assisted living, and 3 in the kitchen.

On 5/27/21 at 12:45 PM, LPA interviewed S1 regarding CCLD's request for facility documents.

No deficiency observed.

Exit interview conducted and a copy of report was provided.

SUPERVISOR'S NAME: Kevin Mknelly	TELEPHONE: (209) -81-1925
LICENSING EVALUATOR NAME: Pheej Cheng	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2021

LIC809 (FAS) - (06/04)

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