<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 475920312
Report Date: 09/30/2025
Date Signed: 09/30/2025 04:22:23 PM

Document Has Been Signed on 09/30/2025 04:22 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 CAREFACILITY NUMBER:
475920312
ADMINISTRATOR/
DIRECTOR:		PACHECO, CINDYFACILITY TYPE:
740
ADDRESS:351 BRUCE STTELEPHONE:
(530) 842-4300
CITY:YREKASTATE: CAZIP CODE:
96097
CAPACITY: 99CENSUS: 53DATE:
09/30/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Administrator Cindy Conley PachecoTIME VISIT/
INSPECTION COMPLETED:
04:45 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
09/30/2025 at 11:30 AM Licensing Program Analysts (LPA) Sarah Benson arrived at the facility to conduct the scheduled pre-licensing inspection. LPA met with administrator Cinde Conley Pacheco and explained the purpose of the visit.
Comp 3 was presented by LPA’s to licensee during the visit. Comp 3 presentation was completed.
The fire marshal has approved the fire safety inspection request. The facility is licensed for 84 non-ambulatory residents and 15 bed ridden residents for a total capacity of 99. The facility has a memory care unit that has seven (7) bedrooms and number (7) bathrooms. The facility also has an assisted living section that has fifty-eight (58) bedrooms and fifty-eight (58) bathrooms.
The LPA observed dining area with water damage, dry wall in the ceiling was removed in an area of twenty feet by twenty feet and covered with plastic sheeting taped over opening. LPA observed a seating area with seating for fifty people in the common area. The hot water meets the requirement for licensing within a range of 105 - 120 degrees F. Food storage meets Title 22 regulation requirements. Plates, utensils, pots, and pans were in place during the inspection. Dishwasher, stove, microwave and refrigerator were all present and working. Bedrooms were observed to have furniture as required by Title 22 Regulations. All beds were made up with linens and bedspreads. Each bedroom has ample storage. The facility has a linen closet which contains sheets, pillowcases, towels and face cloths. Bathrooms were observed to be in good repair. The facility has a locked medication cart which is located in the locked medication room.
Storage and lighting are adequate in the facility. Cleaning supplies and toxins are locked in janitorial rooms. Knives are locked up in the kitchen. Washers and dryers observed in place and ready for use. The facility has 21 Fire Extinguishers fully charged fire extinguishers which were inspected by the fire marshal. LPA observed smoke alarms and carbon monoxide detectors fully functioning. There is a locked office space where client and staff files are stored. The yard has a nice, shaded structure with outdoor furniture for residents to use. The applicants will complete the POC for deficiencies and repair the dinning room water damage to complete pre-licensing. When completed the LPA will contact the Central Application Bureau. The following deficiencies are being cited on the attached LIC809-D in accordance with California Code of Regulations, (Title 22). Exit interview completed and a copy with appeal rights given to the administrator.
NAME OF LICENSING PROGRAM MANAGER: Lauren Crocker
NAME OF LICENSING PROGRAM ANALYST: Sarah Benson
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 4
Document Has Been Signed on 09/30/2025 04:22 PM - It Cannot Be Edited


Created By: Sarah Benson On 09/30/2025 at 03:55 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 09/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above in thriteen (13) medications were found in a residents room which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/30/2025
Plan of Correction
1
2
3
4
Training the staff of medication regulations.
Conversation with family of medication regulations.
Administrator will notify LPA when complete.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lauren Crocker
NAME OF LICENSING PROGRAM MANAGER:
Sarah Benson
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 09/30/2025 04:22 PM - It Cannot Be Edited


Created By: Sarah Benson On 09/30/2025 at 03:55 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 09/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(2)
Personal Accommodations and Services
(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview the licensee did not comply with the section cited above in memory care two resident rooms had no call system cords, two cords were too shrort for use. The dinning room has a twenty by twenty foot hole in the celing with a plastic covering which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/30/2025
Plan of Correction
1
2
3
4
Maintaince will repair the hole in celing.
Maintance will replace the pull cords for the call system in memory care and order more pagers.
Staff will keep pagers on hand, not in the drawer with working batteries. Administrator will complete pager training.
Administrator will notify LPA when complete.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lauren Crocker
NAME OF LICENSING PROGRAM MANAGER:
Sarah Benson
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2025


LIC809 (FAS) - (06/04)
Page: 4 of 4