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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803802
Report Date: 01/10/2025
Date Signed: 01/10/2025 10:57:41 AM

Document Has Been Signed on 01/10/2025 10:57 AM - 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/
DIRECTOR:		HICKS, JACQUELINEFACILITY TYPE:
738
ADDRESS:5939 PLEASANTS VALLEY RDTELEPHONE:
(707) 452-0592
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 5CENSUS: 3DATE:
01/10/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Kelly Arent, Registered Nurse and Dr. BackstromTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct a Case Management visit regarding a self-reported incident regarding client C1. LPA met with North Star #1's registered nurse Kelly Arent and Dr. Backstrom. Administrator Jacqueline Hicks was out of the facility. There were 3 clients on site at the time of visit and 10 staff on site.

The report involves concerns of abuse and neglect of C1. An internal investigation revealed that there was no abuse or neglect. C1 has substantial behaviors which make care multi-layered, including caregiving, behavior management, medical supervision, as well as parental support. LPA reviewed records that indicate that C1 is receiving multi-leveled supportive care with constant supervision and revision to C1's care plan as needed. LPA observed C1 resting in bed, and from what could be observed, was clean and comfortable. C1 responded to LPA that they were comfortable. C1's room was clean, well-maintained, with many personal belongings that provide C1 with personal satisfaction and comfort.

LPA found the facility to be clean, sanitary and well-maintained. LPA observed two other residents who also appeared to be well-cared for; clean, appropriately dressed and engaged with their support staff.

LPA found no concerns for the safety or well-being of the clients in care.

No deficiencies were found at the time of inspection. No citations issued.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 01/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/10/2025
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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