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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803984
Report Date: 06/23/2022
Date Signed: 06/23/2022 11:19:39 AM


Document Has Been Signed on 06/23/2022 11:19 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: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:
06/23/2022
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Facility Representative, Tracy VargasTIME COMPLETED:
11:30 AM
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At approximately 10:25AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Collateral Visit and met with Staff Member, Tracy Vargas. The purpose of the visit was to review and obtain facility records concerning a former resident.

Administrator, James (Jim) Sirokman was available by telephone. After speaking with Administrator, LPA Felias determined that LPA will visit facility another time to conduct record review. Administrator gave verbal permission for Staff Member, Tracy Vargas, to sign LIC-809 document.

No Deficiencies Cited.

Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2022
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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