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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 03:40:54 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
06/04/2026 and conducted by Evaluator Sarah Benson
COMPLAINT CONTROL NUMBER: 59-AS-20260604153534
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:
01:35 PM
MET WITH:Administrator Cinde Conley PachecoTIME COMPLETED:
02:42 PM
ALLEGATION(S):
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Staff are not repositioning resident.
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 records, medical records, MAR and plan of care.

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 3
Control Number 59-AS-20260604153534
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 are not repositioning resident.

During staff interviews, S1 stated when I am with care staff they are repositioning the residents but can do better at recording it. S1 stated that R1 is not happy with repositioning at times and uncomfortable with pillows for support at times. S2 stated at one point our staff tried to assist the resident to a bedside chair. S2 stated during the transfer R1 lifted their feet requiring staff to hold R1’s body weight making it very difficult for staff. S2 stated R1 was very unstable with their core and not stable enough to sit alone.

S2 stated I reposition the resident, S2 stated at the beginning it was difficult to reposition because of R1's bloat and pain. S2 stated R1 was put on lasix and then we were able to move her. S2 stated R1 would panic when put on her side, she thought she might fall out of bed.

S2 stated R1 could not stand to transfer, she could not or would not stand anymore. S2 stated It took four of us to get R1 out of bed, so Hospice gave orders to not get her out of bed, it was too dangerous.



LPA observed R1 is on Hospice with orders to reposition resident every 2 hours.
LPA's record review of resident care log, revealed the majority of the time there is no record of repositioning/transferring of R1.

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: 2 of 3
Control Number 59-AS-20260604153534
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
87633(d)
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Hospice Care of Terminally Ill Residents
(d) The licensee shall ensure that the hospice care plan is current, accurately matches the services actually being provided, and that the client’s care needs are being met at all times.

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Administrator will have a staff training of hospice care and record keeping.
Administrator will have staff notify them when unable to meet the needs of residents in care.
Administrator will notify LPA when completed.
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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, the majority of the time there is no record of repositioning/transferring of R1.
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)
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