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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803802
Report Date: 04/19/2024
Date Signed: 04/19/2024 02:01:55 PM

Document Has Been Signed on 04/19/2024 02:01 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:NORTH STAR #1FACILITY NUMBER:
486803802
ADMINISTRATOR/
DIRECTOR:		HICKS, JACQUELINEFACILITY TYPE:
738
ADDRESS:5939 PLEASANTS VALLEY RDTELEPHONE:
(707) 452-0592
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 5CENSUS: 2DATE:
04/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:16 PM
MET WITH:Adlaine Alfonso H.S., and Shelita Majied Program AssistantTIME VISIT/
INSPECTION COMPLETED:
02:10 PM
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LPA Hiratsuka conducted this unannounced annual visit.

LPA toured the facility with Program Assistant Shelita Majied. This facility has a fire clearance for three non-ambulatory and two ambulatory residents. There are currently two residents who were at their day programs during this visit. There are five private resident rooms and two full common bathrooms. There is a separate office building and another building that may be used by the residents.

One of two resident files were reviewed and six staff training records were reviewed.

The following shall be updated and submitted to Community Care Licensing Division by May 3, 2024:
-LIC 500- facility personnel or staff schedule
-LIC 308 designation of administrative responsibility

Several topics were discussed.

No deficiencies cited.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2024
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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