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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803802
Report Date: 03/06/2025
Date Signed: 03/06/2025 03:38:10 PM

Document Has Been Signed on 03/06/2025 03:38 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/
DIRECTOR:
HICKS, JACQUELINEFACILITY TYPE:
738
ADDRESS:5939 PLEASANTS VALLEY RDTELEPHONE:
(707) 452-0592
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 5CENSUS: 3DATE:
03/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Program Director, Kim Royce and Administrator Jacqueline Hicks TIME VISIT/
INSPECTION COMPLETED:
03:40 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 Administrator Jacqueline Hicks and allowed entry into the facility.

The facility currently has 3 residents in care. The facility has the main building which includes clients' bedrooms, the kitchen, dining area, family room, and 2 bathrooms, laundry room and sensory room. There are several outbuildings which include a garage set up for client use, an office building for staff and conferences, and a large barn, which is not currently in use. The facility has substantial grounds for clients to enjoy. There is a gazebo with comfortable seating and plenty of shade, a trampoline, and lots of areas to walk.

LPA and Administrator toured the facility, which was a comfortable temperature. The clients' rooms and common areas were clean and well organized. The water temperature was within regulation of 105 - 120 degrees F. There was an ample supply of perishable and non-perishable foods. The fire/smoke/carbon monoxide detectors were inspected on 02/28/2025. The fire extinguishers were last inspected on 05/22/2024 and were fully charged.

Clients appeared well-cared for and engaged with activities and staff.

LPA reviewed 3 client files and 5 staff files. All were found to be complete.

No deficiencies found during today's inspection.
No citations issued.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2025
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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