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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 475920312
Report Date: 03/04/2026
Date Signed: 03/11/2026 01:05:46 PM

Document Has Been Signed on 03/11/2026 01:05 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, CINDEFACILITY TYPE:
740
ADDRESS:351 BRUCE STTELEPHONE:
(530) 842-4300
CITY:YREKASTATE: CAZIP CODE:
96097
CAPACITY: 99CENSUS: 46DATE:
03/04/2026
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:57 PM
MET WITH:Receptionist Patti DanielsTIME VISIT/
INSPECTION COMPLETED:
05:45 PM
NARRATIVE
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On March 4, 2026 Licensing Program Analyst LPA Sarah Benson arrived at the facility unannounced to complete a post-licensing visit. The facility was initially licensed on 09-30-2025. LPA was greeted by Receptionist Patti Daniels. The facility is licensed for ninety-nine (99) residents and currently has (46) forty-six. The facility has an approved hospice waiver for fifteen (15) and currently has four (4) residents on hospice.
LPA completed the Facility Inspection Tool. Areas inspected include but are not limited to resident apartments, common areas, kitchen, outside patio, and medication rooms. The facility is in good condition, clean and nicely furnished. The facility is well furnished with appropriate furniture, dishes, pots and pan, etc. LPA and staff toured two (2) residents apartments in the memory care unit, residents apartments were found to be clean and in good repair, hot water temperature was measured in apartments and was within the required range of 105-120 degrees F. LPA and staff toured two (2) assisted living apartments. Resident apartments were found to be clean and in good repair, hot water temperature was measured in apartments and was within the required range of 105-120 degrees F. Lighting is appropriate throughout the facility. Food supplies were reviewed and appear appropriate to meet the requirement of 2 days perishable and 7 days non-perishable supplies.
LPA reviewed staff records and client records.
Staff records include fingerprint clearance, physician reports, TB clearance, current First Aid/CPR certification, records of ongoing training. Administrator certificates are current.
Resident files include signed admission agreements, updated physician reports, assessments, care plans, signed consents, rights, etc.
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 was given to the administrator.
NAME OF LICENSING PROGRAM MANAGER: Lauren Crocker
NAME OF LICENSING PROGRAM ANALYST: Sarah Benson
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2026
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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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)
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Document Has Been Signed on 03/11/2026 01:05 PM - It Cannot Be Edited


Created By: Sarah Benson On 03/04/2026 at 05:11 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: 03/04/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87613(a)(2)(B)
General Requirements for Restricted Health Conditions
(2) Ensure that facility staff who will participate in meeting the resident's specialized care needs complete training provided by a licensed professional sufficient to meet those needs. (B) Training shall be completed prior to the staff providing services to the resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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 Based on observation, interview and record review, the licensee did not comply with the section cited above in one out of two persons did not have training recorded in staff file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/04/2026
Plan of Correction
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The administrator will have staff complete required training before staring work.
The administrator will send a copy to LPA of training when complete.
The administrator will place a copy in staff file when complete.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in the facility had no record of quartly drill, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/06/2026
Plan of Correction
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The facility will plan and perform a quartley drill.
The Administrator will send a copy of quartley drill to LPA when complete.
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: 03/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2026


LIC809 (FAS) - (06/04)
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