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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803984
Report Date: 09/27/2024
Date Signed: 09/27/2024 12:18:26 PM


Document Has Been Signed on 09/27/2024 12:18 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:FIVE ACRES AT LEISURE TOWN NORTHFACILITY NUMBER:
486803984
ADMINISTRATOR:SIROKMAN, JAMESFACILITY TYPE:
740
ADDRESS:5073 VICTOR LANETELEPHONE:
(949) 439-2836
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY:11CENSUS: 10DATE:
09/27/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Heather Fish, Lead Care StaffTIME COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct an inspection regarding an incident filed on 05/31/2024.

LPA met with Heather Fish, Lead Care Staff. Administrator James Sirokman was out of town, but available by phone. LPA conducted an inspection of the facility and found it to be clean and well-maintained. Residents appeared well-cared for and appropriately dressed. Lunch was being prepared at the time of inspection and there was an ample supply of perishable and non-perishable foods, which were stored as per regulation.

LPA reviewed facility records and found that staff member S1, who was named in the incident report had been terminated.

There were no citations issued.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2024
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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