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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 475002711
Report Date: 05/27/2021
Date Signed: 05/27/2021 03:59:10 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:
05/27/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Elaine Brauer; AdministratorTIME COMPLETED:
05:00 PM
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On 5/27/21 at 2PM, Licensing Program Analyst (LPA) Cheng conducted an unannounced Case Management visit and met with Administrator Elaine Brauer. 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.

The purpose of LPA's visit was to delivering an Order To Individual of Immediate Exclusion from all facilities and the Order to Licensee/Facility of Immediate Exclusion From Facility. LPA informed with Administrator Elaine Brauer the purpose of today's visit .LPA delivered notice of "Immediate Exclusion" to Administrator Elaine Brauer and explained the "Immediate Exclusion" notice indicating that prior employee, Michelle Snodgrass, cannot be allowed to work, be present and/or live in a CCL licensed facility and have contact with clients in any residential facility or child day care licensed by the California Department of Social Services. LPA was informed by Administrator Brauer that Snodgrass was terminated from employment on 5/24/2021 and last worked on 5/18/2021.

A copy of this report was provided to Administrator
SUPERVISOR'S NAME: Kevin MknellyTELEPHONE: (209) -81-1925
LICENSING EVALUATOR NAME: Pheej ChengTELEPHONE: (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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