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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 475002711
Report Date: 06/03/2021
Date Signed: 06/03/2021 10:09:04 AM

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: 60DATE:
06/03/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Elaine Brauer, AdministratorTIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) Valencia 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: surgical Masks and gloves. Additionally, LPA was screened by front desk personnel.

LPA toured the facility inside and out including but not limited to facility dining areas, break rooms, kitchen area, and memory care unit (MCU). LPA observed that all clients are clear to wander as long as they are social distancing an wearing masks. 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. All staff not working were wearing a surgical masks.

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. 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 two times a day and keeps a log of it. LPA observed that there are currently the following staff members working: 3 in MCU, 5 in Assisted living, 3 housekeepers and 3 in the kitchen.

No deficiency observed. Exit interview conducted and a copy of report was provided.
SUPERVISOR'S NAME: Kevin MknellyTELEPHONE: (209) -81-1925
LICENSING EVALUATOR NAME: Misty ValenciaTELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2021
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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