Siskiyou Springs Assisted Living and Me

Type of visit: Case Management - Incident

On June 12 2026, Licensing Program Analyst (LPA) Sarah Benson arrived at the facility to open two complaints and conduct an unannounced case management in response to a phone call received from a family member 6-12-26. The family member stated they had called the facility three times and were unable to talk to staff. LPA met with Resident Care Coordinator and explained the purpose of the visit. LPA Benson and Resident Care Coordinator (RCC) inspected the memory care unit. LPA Benson observed residents playing bingo. LPA Benson left resources for facility activities. See attached 812's for interviews. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. An exit interview was conducted, and a copy of the report and appeal rights were provided. LPA Benson and Resident Care Coordinator (RCC) inspected the memory care unit and hospice residents rooms. Upon entering the memory care unit LPA Benson observed an over powering cleaning solution or air freshener smell. LPA Benson observed the laundry room open with a gallon size container of laundry soap left unattended. RCC closed the locked door to laundry room so the laundry soap was locked in storage area with LPA present. LPA observed resident rooms and bath rooms clean with required supplies. See attached 812's. Continued on LIC809Dthe state’s words, verbatim · CDSS document, Jun 12, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87309(a) · Plan of correction due date: Jun 12, 2026

87309 Storage Space and Access (a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. Based on observation, the licensee did not comply with the section cited above. The laundry room door was left open with cleaning solutions unattended, which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 12, 2026

Plan of correction: The RCC closed the locked door during LPA visit. The administrator will have a staff training concerning keeping cleaning solutions locked.

Type of visit: Post Licensing

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.the state’s words, verbatim · CDSS document, Mar 4, 2026

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

On 1-2-26 Licensing Program Analyst LPA Sarah Benson arrived at the facility unannounced to conduct a case management visit. LPA Benson met with Administrator Cindy Conley Pacheco and explained the purpose of the visit. The department is following up on an incident report sent by the facility on 12-29-25 stating that a resident, R1 had a un-witnessed fall with a broken hip requiring surgery. The LPA performed interviews and records were reviewed. LPA Benson and Administrator toured the facility together. LPA Benson observed the repair to the dinning room ceiling was completed and the pull cords in memory care are all working. When testing the pull cords it was discovered the pager was not working. The staff used a screw driver to repair the pager during LPA's visit. It was discovered the floors in the residents rooms were not clean. 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. Exit interview conducted and copy of the report left with the administrator.the state’s words, verbatim · CDSS document, Jan 2, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Feb 2, 2026

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:The floors in the residents rooms had large dust bunnies, dust, hair balls, paper scraps and food under the beds and around the baseboards. which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 2, 2026

Plan of correction: Administrator will assign house keeping to clean the memory care area. Admistrator will notify LPA when the memory care is clean. A staff member weekly will be resonsible to verify the cleaning check list is completed.

Type of visit: Prelicensing

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.the state’s words, verbatim · CDSS document, Sep 30, 2025

Type of visit: Case Management - Deficiencies

On 8-13-25 Licensing Program Analyst LPA Sarah Benson arrived unannounced at the facility to deliver complaint findings for previously licensed facility Siskiyou Springs Senior Living Community (475002711. LPA Benson met with Administrator Cindy Pacheco. LPA Benson and the Administrator toured the facility together. See the following complaint findings: SISKIYOU SPRINGS SENIOR LIVING COMMUNITY, 475002711. 59-AS-20250402153648 reported 4-02-25: 2 complaints Unsubstantiated. 59-AS-20250415150958 reported 4-15-25: 1 complaint Substantiated. 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. An exit interview conducted and a copy of the report was left with Administrator.the state’s words, verbatim · CDSS document, Aug 13, 2025

Allegation investigated: Facility pager system is in disrepair.

/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 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.the state’s words, verbatim · CDSS document, Jul 29, 2025 · control 59-AS-20250728170457

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(i)(1)(A)(B)(C) · Plan of correction due date: Aug 29, 2025

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. 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.the state’s words, verbatim · CDSS document, Jul 29, 2025

Plan of correction: 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.

Type of visit: Case Management - Other

On 5-19-25 Licensing Program Analyst LPA Sarah Benson arrived at the facility unannounced to deliver complaint findings for previously licensed facility (475002711). LPA Benson met with Carey Eppler Office Manager.the state’s words, verbatim · CDSS document, May 20, 2025

Type of visit: Case Management - Other

On 5-20-25 Licensing Program Analyst LPA Sarah Benson arrived at the facility unannounced to amend complaint findings for previously licensed facility (475002711). LPA Benson met with Carey Eppler Office Manager.the state’s words, verbatim · CDSS document, May 20, 2025