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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803802
Report Date: 04/12/2022
Date Signed: 04/12/2022 03:45:05 PM

Document Has Been Signed on 04/12/2022 03:45 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: 2DATE:
04/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Jacqueline Hicks, AdministratorTIME COMPLETED:
03:53 PM
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Licensing Program Analyst (LPA) Walters arrived unannounced for the purpose of conducting a Required 1 Year annual inspection. LPA met with Jacqueline Hicks, Administrator. This visit will focus on the infection control of this facility. The facility submitted an infection control mitigation plan on 01/06/2022 which was approved by Community Care Licensing. The facility currently has 2 clients in care.

LPA toured the facility and grounds with Administrator and made the following observations: COVID-19 precaution signs posted in common areas to promote social distancing. The facility has designated the garage as the visitor check-in area. There, LPA was screened for COVID-19 symptoms and had temperature checked. LPA also observed at least a 30 day supply of Personal Protective Equipment (PPE), incontinence products and cleaning products. Upon entrance to the facility, the Administrator has posted COVID-19 reference sheets for staff. Other Infection control practices that are present are: creating designated visiting areas, face coverings and sick leave policy. Per Administrator, Staff disinfectant daily and after usage.

LPA reviewed staff and client records which indicate that staff and clients have received their vaccines. Vaccine records are stored in client and staff files. LPA and Administrator discussed documenting staff infection control training's, including the duration and topic, and having training's signed by staff. Client's are screened daily on Medication administration records (MAR). Clients and staff who are not vaccinated are tested weekly. Internal and External group activities are developed weekly, that foster physical distancing. Facility has an activity board which includes museum outings, parks and trips to farmers market. Administrator was unable to complete visit with LPA. LPA conducted exit interview with Adlaine Alfonso, back-up Administrator. No deficiencies cited during today's visit.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2022
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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