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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 475920312
Report Date: 07/29/2025
Date Signed: 07/29/2025 10:37:54 AM

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
07/28/2025 and conducted by Evaluator Sarah Benson
COMPLAINT CONTROL NUMBER: 59-AS-20250728170457
FACILITY NAME:SISKIYOU SPRINGS ASSISTED LIVING AND MEMORY CAREFACILITY NUMBER:
475920312
ADMINISTRATOR:PACHECO, CINDYFACILITY TYPE:
740
ADDRESS:351 BRUCE STTELEPHONE:
(530) 842-4300
CITY:YREKASTATE: CAZIP CODE:
96097
CAPACITY:99CENSUS: 56DATE:
07/29/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator Cindy PachecoTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Facility pager system is in disrepair.
INVESTIGATION FINDINGS:
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07/29/2025 at 10:00 AM Licensing Program Analysts (LPA) Sarah Benson made an unannounced visit to the facility and met with Administrator Cindy Pacheco. The purpose of this visit was to open a complaint investigation.

During today's visit the facility was toured, records were reviewed and interviews were performed.
LPA Benson interviewed 3 staff members. LPA requested the following documents during the visit: staff list with telephone numbers and staff schedule, client roster and incident reports.



Continued on 9099C and 9099D
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2025
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 3
Control Number 59-AS-20250728170457
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 ASSISTED LIVING AND MEMORY CARE
FACILITY NUMBER: 475920312
VISIT DATE: 07/29/2025
NARRATIVE
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During staff interviews, it was reported that the electricity and call system went out 7-16-25 at 5:30 am. Staff stated, I made sure all of the residents were checked on every hour. The Administrator reported the most critical residents in assisted living had their doors propped open so staff could hear/attend to them. The administrator reported most of the residents had cell phones and were told to call the front desk when needing staff. The administrator stated the staff were required to check in on each resident at least every forty-five minutes. The administrator reported that the call system is set up to forward the calls to the memory care staff when the front desk staff go home.

Staff reported the generator was working and the electricity came back on 7-16-25 at about 10:00am but the call system did not. Staff reported the downed call system to the company in charge. Staff reported by 7-18-25 the company said the system files were corrupt and said we had to get a new system. Staff reported on searching for a new system. Staff reported on 7-21-25 the old system began working again.

LPA Benson and staff observed the call system in the office area in working order. Staff stated we are trying to verify where the outlets are that are connected to the generator. Staff stated I want to make sure the call system is connected to the generator. LPA Benson went to room 105 with staff to test the call system. Staff pushed the residents call button at 2:29 pm and staff arrived at 2:37 pm. LPA Benson observed the call system as working.

During file review it was discovered that the assisted living area has four care staff during the day and two care staff during the night. File review revealed that memory care has two care staff during the day and two care staff during the night. Record review revealed that the facility has two care staff in momory care and 1 care staff in assisted living for the NOC shift.

Based on investigation observations, record review(s) and interviews which were conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D. Appeal rights were explained and provided to the facility representative listed above and exit interview conducted. If any of the cited deficiencies are not corrected by the noted due date, civil penalties may be assessed.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 59-AS-20250728170457
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 ASSISTED LIVING AND MEMORY CARE
FACILITY NUMBER: 475920312
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/29/2025
Section Cited
CCR
87303(i)(1)(A)(B)(C)
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87303 Maintenance and Operation
(i) Facilities shall have signal systems which shall meet the following criteria:
(1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (A) Operate from each resident's living unit. (B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. (C) Identify the specific resident living unit.
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The administrator will create a policy for staff to follow when the call system is not working.
The administrator will send a copy of the new policy to LPA.
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This requirement is not met as evidenced by: The facility had no signal system in working order from 7-16-25 until 7-21-25. . This poses an immediate Health and Safety risk to residents in care.
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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.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2025
LIC9099 (FAS) - (06/04)
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