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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803984
Report Date: 08/18/2023
Date Signed: 08/18/2023 02:05:30 PM


Document Has Been Signed on 08/18/2023 02:05 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: 8DATE:
08/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Jim Sirokman, AdministratorTIME COMPLETED:
02:15 PM
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On 8/18/2023, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection visit for this facility and was greeted by Administrator, Jim Sirokman. The facility is single story building licensed for 11 bedridden residents, along with a hospice waiver capacity of 6. The facility currently provides care for 8 residents, 2 of which is receiving hospice services and some residents with a diagnosis of dementia.

LPA continued with a tour of the facility with Administrator, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 5/16/2023. Both smoke detectors and carbon monoxide detectors throughout the facility were interconnected, tested and found to be in working order. The facility is equipped with an additional sprinkler system. Administrator agrees to contact the company that conducted the inspection and request for copies of the inspection documentation. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations with food properly stored. Toxins stored in designated cabinets located in the laundry room and a storage shed located in the backyard which were both found to be secured.

There was a supply of hygiene products and paper products available for residents. All resident bedrooms have lighting & appropriate furnishings. Water was measured at faucets accessible to residents and measured between 115.7 and 120.0 degrees F which is within regulation.


Continued onto LIC809-C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:
DATE: 08/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2023
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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: FIVE ACRES AT LEISURE TOWN NORTH
FACILITY NUMBER: 486803984
VISIT DATE: 08/18/2023
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Medications located in secured carts in the staff office and were found to be secured. LPA conducted a spot check of medications and found all administering and records to be in order. Facility has transitioned to utilizing Centrally Stored Medication Records on an electronic system. During inspection LPA found that facility is utilizing a new electronic system for the medication destruction process that requires additional training to be completed. Several medications were in need of proper disposal. Administrator agrees to develop a plan of action to ensure compliance and complete staff training on the new medication destruction process. Technical Advisory issued.
Resident were observed interacting with staff in the common area, visited by family or resting in their bedrooms for leisure. There are two emergency exits located in the backyard which were found to be unobstructed. All auditory alarms leading out of the facility send chime to the office and staff pagers and were all in working order.

LPA conducted a sample file review for staff and found staff to have updated 1st aid & CPR training on file. The facility has previously addressed current plan of action on reconciling facility records as of May 2023. Facility is working with management agency to ensure all facility files are current. Due to current record reconciling, Administrator is in the process of updating all staff annual training. LPA was shown of staff training template from previous years and facility training plan exceeds annual training requirements. Administrator agrees to submit a plan of action on how the facility will meet the 20 hours of annual training and a copy of the training template for review. Technical Advisory Issued.

Administrator, Jim Sirokman's Administrator Certification is currently pending. LPA confirmed that training and documents have been submitted for renewal. Certification 6045410740 application and payment was received as of 7/7/2023.

LPA requested the following documents be sent to CCL by COB 9/18/2022:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Liability Insurance

No deficiencies cited during today's visit.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2023
LIC809 (FAS) - (06/04)
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