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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 475002711
Report Date: 06/12/2021
Date Signed: 06/12/2021 11:01:35 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: 62DATE:
06/12/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Facility Manager Barbara WilliamsTIME COMPLETED:
11:30 AM
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On 06/12/2021, at 10:50am, Licensing Program Analyst (LPA) Misty Valencia accompanied by Investigation bureau Investigator (IBI) conducted an unannounced Case Management visit and met with Facility Manager Barbara Williams. Prior to initiating the visit, LPA and IBI 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 Manager 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 Facility Manager Barbara Williams with the purpose of today's visit .LPA delivered notice of "Immediate Exclusion" to Facility Manager Barbara Williams and explained the "Immediate Exclusion" notice indicating that prior employee, Administrator Elaine Brauer, 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.

A copy of this report was provided to Facility Manager Barbara Williams
SUPERVISOR'S NAME: Kevin MknellyTELEPHONE: (209) -81-1925
LICENSING EVALUATOR NAME: Misty ValenciaTELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2021
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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