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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803802
Report Date: 06/30/2022
Date Signed: 06/30/2022 02:49:00 PM

Document Has Been Signed on 06/30/2022 02:49 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:NORTH STAR #1FACILITY NUMBER:
486803802
ADMINISTRATOR:HICKS, JACQUELINEFACILITY TYPE:
738
ADDRESS:5939 PLEASANTS VALLEY RDTELEPHONE:
(707) 452-0592
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 5CENSUS: 3DATE:
06/30/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:26 PM
MET WITH:Administrator, Jacqueline HicksTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Walters and IB investigator, Brianna Abeyta (BA) arrived unannounced to follow up on a self-reported incident. LPA and BA were greeted by Administrator, Jacqueline Hicks.

The facility self reported on 4-14-22, that staff S1 and S2 were assigned to provide care and supervision for client C1, however when Administrator arrived to the facility on 4-14-22, The Administrator learned that C1 was without supervision. The facility submitted an incident report regarding the incident and the Administrator provided a statement. Staff S1, resigned and Staff S2 was taken off of their shifts, pending the investigation. In review of C1's Individual Behavior Support Plan and Treatment Plan, C1 requires 1:1 supervision for support.

Appeal Rights Provided.

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. Exit interview conducted with Jacqueline Hicks, Administrator, who's signature below confirms receipt of report.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE: DATE: 06/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/30/2022
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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Document Has Been Signed on 06/30/2022 02:49 PM - It Cannot Be Edited


Created By: Katrina Walters On 06/30/2022 at 02:08 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: NORTH STAR #1
FACILITY NUMBER: 486803802

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/04/2022
Section Cited
CCR
85078(a)(1)

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85078 Responsibility for Providing Care and Supervision (a) In addition to Section 80078, the following shall apply: (1) The licensee shall provide those services identified in the client's needs and services plan as necessary to meet the client's needs. This requirement was not met as evidenced by:
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Faciltiy will submit proof of staff training and documentation including attendess, and dates and time of training by POC due date.
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Based on LPAs record review, and interviews there was lack of supervision for client C1, staff failed to properly supervise client in care. This poses an immediate health and safety risk to clients 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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Katrina Walters
LICENSING EVALUATOR SIGNATURE:
DATE: 06/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2022


LIC809 (FAS) - (06/04)
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