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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803802
Report Date: 02/24/2023
Date Signed: 02/24/2023 01:34:35 PM

Document Has Been Signed on 02/24/2023 01:34 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: 4DATE:
02/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Jacqueline Hicks, Administrator and StaffmembersTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced for the purpose of conducting a Required 1 Year annual inspection. LPA was greeted by staff and asked to get temperature check and sign-in.

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 4 residents in care; 3 were on site at the time of visit, and the 4th resident was attending Day Program.

LPA and staff member toured the facility, which was going through some renovations: drywall repairs. Despite all the construction, the clients' rooms and common areas were clean and well organized. The residents and staff were handling the construction well, and they anticipated the construction to be completed within days.

COVID-19 signs were posted at all entrances, in the kitchen and in staff area. The facility has designated the garage/office as the visitor check-in area. The facility has a 30 day supply of Personal Protective Equipment (PPE), incontinence products and cleaning products. Staff and clients are currently screened weekly for Covid-19, and if there is a case the screening is increased to twice a week. Facility has an activity board which includes museum outings, parks and trips to farmers market.

No deficiencies found during today's inspection.
No citations issued.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2023
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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