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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 475920312
Report Date: 09/21/2026
Date Signed: 09/21/2026 05:23:45 PM

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
06/02/2026 and conducted by Evaluator Sarah Benson
COMPLAINT CONTROL NUMBER: 59-AS-20260602164239
FACILITY NAME:SISKIYOU SPRINGS ASSISTED LIVING AND MEMORY CAREFACILITY NUMBER:
475920312
ADMINISTRATOR:PACHECO, CINDEFACILITY TYPE:
740
ADDRESS:351 BRUCE STTELEPHONE:
(530) 842-4300
CITY:YREKASTATE: CAZIP CODE:
96097
CAPACITY:99CENSUS: 49DATE:
09/21/2026
UNANNOUNCEDTIME BEGAN:
12:32 PM
MET WITH:Administrator Cinde PachecoTIME COMPLETED:
01:33 PM
ALLEGATION(S):
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Facility is not giving resident their pain medications.
INVESTIGATION FINDINGS:
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On 09-21-26, Sarah Benson, Licensing Program Analyst (LPA) arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 06-02-26. LPA Benson met with Administrator Cinde Pacheco and explained the purpose of the visit.

During the interview process, three staff persons and one resident were interviewed. The following documents were received and reviewed: staff list with telephone numbers and work schedule, client roster, client admission agreements, hospice care records, medical records, MAR, cleaning schedule and care plan.

Substantiated
Continued on LIC9099C and LIC9099D
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2026
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 5
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
06/02/2026 and conducted by Evaluator Sarah Benson
COMPLAINT CONTROL NUMBER: 59-AS-20260602164239

FACILITY NAME:SISKIYOU SPRINGS ASSISTED LIVING AND MEMORY CAREFACILITY NUMBER:
475920312
ADMINISTRATOR:PACHECO, CINDEFACILITY TYPE:
740
ADDRESS:351 BRUCE STTELEPHONE:
(530) 842-4300
CITY:YREKASTATE:CAZIP CODE:
96097
CAPACITY:99CENSUS: 49DATE:
09/21/2026
UNANNOUNCEDTIME BEGAN:
12:32 PM
MET WITH:Administrator Cinde PachecoTIME COMPLETED:
01:33 PM
ALLEGATION(S):
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3
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9
Staff is not keeping the resident rooms clean.
INVESTIGATION FINDINGS:
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On 09-21-26, Sarah Benson, Licensing Program Analyst (LPA) arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 06-02-26. LPA Benson met with Administrator Cinde Pacheco and explained the purpose of the visit.

During the interview process, three staff persons and one resident were interviewed. The following documents were received and reviewed: staff list with telephone numbers and work schedule, client roster, client admission agreements, hospice care records, medical records, MAR, cleaning schedule and care plan.

Unsubstantiated.
Continued on LIC9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 59-AS-20260602164239
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: 09/21/2026
NARRATIVE
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Staff is not keeping the resident rooms clean.

During staff interviews, S4 stated there have been times the room was in disarray, but not dirty. S3 stated In R1’s previous upstairs room there was a lot of clutter, she didn’t like anyone going through her stuff. S3 stated I moved all of the non-ambulatory people downstairs. S3 stated we moved R1 from upstairs to downstairs and cleaned up her room. S3 stated the family donated a lot of her stuff as her room was cluttered. S3 stated I did see medical wrappers on R1’s floor, I could see that staff had a hard time putting garbage into a garbage can.

LPAs’ observations during the visit: the room to be clean, dust free and orderly. LPA observed the garbage container was emptied.


Although the above allegation mentioned may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the above findings are Unsubstantiated.

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

DATE: 09/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 59-AS-20260602164239
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: 09/21/2026
NARRATIVE
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Facility is not giving resident their pain medications.

During staff interviews, S3 stated staff should ask R1 every shift what their pain level is. S3 stated other staff are resistant to give morphine or Ativan. S3 stated at one point R1 was very sedated, so staff were informed, don’t give pain medication over the weekend. S4 stated there was a transitional period from the prn to the scheduled every 12 hours. S4 stated protocol is check every two hours, the RA’s report if they see any grimacing or restlessness. S4 stated at this time R1 is taking the long last q 12 hours scheduled at this time. S4 stated R1 has had no pain sense then. S4 stated in the past R1 would say her pain was always 8, even after I gave the pain medication. S4 stated If I ask R1 now what her pain level is, she would say no pain. S4 stated we had a med. tech that was negative about hospice outcomes, scared of controlled medication in a syringe. S4 stated I gave the PRN medication as needed.

Record review revealed R1s doctor prescribed pain medication May 21 2026 every hour as needed for pain. Review of the medication administration record, records only one dose given between May 28 and June 3 2026. The resident was not administered their pain medication.

During Resident interviews LPA Benson ask R1 is they were in pain, they reported yes, they are always in pain.

Resident interviews revealed that the resident was in pain. At this time It was reported the resident is getting consistent pain medication and is no longer in pain.

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: 09/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 59-AS-20260602164239
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: 09/21/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/21/2026
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care
(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
(4) The licensee shall assist residents with self-administered medications as needed.
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Administrator will have a staff training concerning Hospice PRN medication and the administration.
Administrator will notify LPA when complete.
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This requirement is not met as evidenced by: Based on observation, interview and record review, the licensee did not comply with the section cited above in the resident was not assisted with medicaion as needed.
Which poses an immediate health, safety or personal rights risk to persons 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.
SUPERVISOR'S NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5