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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803984
Report Date: 03/24/2022
Date Signed: 03/24/2022 04:08:37 PM


Document Has Been Signed on 03/24/2022 04:08 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: 9DATE:
03/24/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
01:17 PM
MET WITH:Administrator, James SirokmanTIME COMPLETED:
04:19 PM
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Licensing Program Analyst (LPA) Walters arrived unannounced for the purpose of conducting a Post-Licensing inspection, and met with Administrator, James Sirokman. The inspection is focused on the Infection Control procedures and practices of this facility. The facility submitted a mitigation plan on 8/26/22, which was approved by this department. LPA conducted a risk assessment with Administrator.

LPA toured the facility and grounds, and made the following observations: At the entrance of the facility there was a sign-in sheet for visitors, with screening questions and a thermometer. Hand sanitizer and disposable mask were made available. There's a viral disinfectant system at the threshold that disinfects visitor's clothing. There were posters at the entrance and throughout the facility to promote contact precautions. Bathrooms were supplied with hand washing supplies, paper products and signs to demonstrate proper hand washing techniques. Facility has at least a 30 day supply of Personal Protective Equipment (PPE) and Incontinence Products. All staff have received infection control training through Local Public Health.

Resident's who are in shared bedroom have beds kept 6 feet apart. In the event that the residents need to isolate, facility has an additional room and is able to isolate individuals who test positive together. High traffic and surface areas are disinfected after every shift and after usage. Staff monitor residents routinely for symptoms. Vitals are recorded in facility database. Staff and Resident's vaccine cards are kept on file. Facility was clean and a comfortable temperature. All exits were free from obstruction. The smoke alarm, sprinkler and carbon monoxide detectors are hardwired and were tested by the Vacaville Fire Department on 5/10/2021. Administrator and LPA discussed having all staff fit tested. Administrator will schedule an appointment with public health. No deficiencies cited during todays visit.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina WaltersTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2022
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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