486803984-8-26-2021-21-AS-KWAS-C69T7Z-20210826142933

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803984
Report Date: 08/20/2021
Date Signed: 08/26/2021 02:29:40 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME:	FIVE ACRES AT LEISURE TOWN NORTH		FACILITY NUMBER:	486803984
ADMINISTRATOR:	UNKNOWN		FACILITY TYPE:	740
ADDRESS:	5073 VICTOR LANE		TELEPHONE:	(949) 439-2836
CITY:	VACAVILLE	STATE: CA	ZIP CODE:	95688
CAPACITY:	11	CENSUS: 0	DATE:	08/20/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	James Sirokman		TIME COMPLETED:	06:35 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Katrina Walters arrived unannounced and met with applicant, James Sirokman for the purpose of conducting a Pre-Licensing inspection. LPA conducted a risk assessment with Applicant, James Sirokman, who will be the Administrator once the license is approved. Five Acres At Leisure Town North is a residential care facility for the elderly. Facility does not currently have any residents in care. This facility is a single story home on 5 acres of property. This home includes: seven bedrooms, an office, two ADA bathrooms, a wet room, medication room, laundry room, an activity room and kitchen. The facilities Fire clearance was granted May 10, 2021 by Dixon Fire Department for 11 non-ambulatory residents. Signs were posted at the entrance of the facility. Disposable mask and hand sanitizer was also available. The facility has designated indoor/outdoor visitation areas. The applicant has submitted a mitigation plan for COVID-19. The facility was inspected and was found to be clean, organized, in good repair. All bedrooms furnished as required by licensing. There were ADA pull handles on each resident bedroom door. Temperature sensors in each bedroom to zone temperature. Bathrooms were equipped with soap, paper towel and grab bars. The grounds were free of any apparent hazards, fire exits were clear. Fire extinguishers were charged. Smoke Detectors, Carbon Monoxide sensors and sprinklers were last inspected on 5/10/2021. All auditory alarms were on and working at the time of inspection. Facility has no firearms. Water temperature measured at 106.1,106.5 and 106.8 in faucets used by residents. Facility has a generator. The facility has a phone line for client use. Personnel records and residents records will be stored in a locked office file cabinets. There is an ample supply of personal hygiene products, bedding and linens, utensils, dishes, and cook ware. There are multiple first aid kits throughout the facility. Continued on 809 C

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: FIVE ACRES AT LEISURE TOWN NORTH	FACILITY NUMBER: 486803984
	VISIT DATE: 08/20/2021

NARRATIVE

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Kitchen was spacious and clean, with an adequate supply of dishes and utensils. Refrigerators were clean, with perishable and non-perishable foods. Kitchen cabinets and several shelves were supplied with can/dry goods, paper products and emergency water. There is a designated locked cabinets to store knives, sharps and all toxins.

The Component III Orientation was completed during today's visit.
LPA conducted Comp 3 review on 8/20/2021 and applicant has knowledge of Title 22 regulations. LPA went over Guardian and forms needed for fingerprint clearance, association, fingerprint transfer requirements and forms that need to be completed, along with phone numbers, fax number and email address. LPA went over AWOL procedures, incident report requirements, posting requirements, required forms for staff and resident,
and new Covid 19 postings and procedures.

This Pre-Licensing is complete. A copy of report to be emailed to Applicant. LPA will submit copy of the facility report to the Application Unit Analyst in Sacramento. The Application Unit Analyst will complete application process and notify applicant of their status.

No deficiencies cited during today's visit.

**Due to technical errors, this is a copy of the original report.The original report with signatures will remain on file***

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021

LIC809 (FAS) - (06/04)

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