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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803984
Report Date: 06/03/2024
Date Signed: 06/03/2024 06:15:23 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/14/2024 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20240314140222
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:
06/03/2024
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:James Sirokman, AdministratorTIME COMPLETED:
06:15 PM
ALLEGATION(S):
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Staff are not properly trained to adminster medications.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Nakagawa and Macias arrived unannounced to continue an investigation into the above allegations and deliver findings. LPAs reviewed documents, made observations and conducted interviews.
The complaint alleges that personnel files are unorganized and may be out of date, as well as not accurately showing training of staff to administer medications and complete the Centrally Stored Medication List. LPA’s inspection of the facility on 6/03/2024 found that training records were not current. Training records had been found incomplete on 8/8/2023 during a prior inspection and Licensee had not updated the training records as of the inspection on 6/3/2024.

Continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 21-AS-20240314140222
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/03/2024
NARRATIVE
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Continued from 9099-C.

Based on LPA’s review of personnel files; there are a lack of records to indicate that Staff are properly trained to adminster and/or document medication records. The allegation that Staff are not properly trained to adminster medications is SUBSTANTIATED.

The California Code of Regulations cited on the attached LIC9099D.
Deficiencies are cited from the California Code of Regulations (CCRs). Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/14/2024 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20240314140222

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:
06/03/2024
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:James Sirokman, AdministratorTIME COMPLETED:
06:15 PM
ALLEGATION(S):
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Staff leave residents in bed for an extended period of time.
Staff do not properly lock resident's medications
Staff are not background cleared to care and supervise residents.
Administration does not meet administrator requirements.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Nakagawa and Macias arrived unannounced to continue an investigation into the above allegations and deliver findings. LPAs reviewed documents, made observations and conducted interviews.

The complaint alleges that residents are left in bed for periods of time. LPAs Nakagawa and Macias conducted inspections on 3/19/24 and 6/3/24 and observed only one resident (R1) in bed at the time of visits. Other residents were out of bed, clean and dressed appropriately. Records indicate that resident (R1) requested to stay in bed until noon. Interview of resident corroborated resident’s personal rights were being respected.
The complaint also alleges Staff do not document resident's medications, Staff do not properly lock medications and the med cart is left unattended and unlocked. LPA inspected facility’s medication records and found that 5 out of 5 medications checked were correct and at the time of inspection medications were found to be properly locked and secured and the med cart was locked inside the locked doors of the administrative office; therefore the allegations Staff do not document resident's medications, Staff do not properly lock medications and the med cart is left unattended and unlocked are UNSUBSTANTIATED.
The complaint also alleges that the Administrator does not have proper certification. The Administrator James Sirokman has a valid RCFE Administrator’s Certificate #7014025740, which is effective to 07/01/2025, therefore the allegation the Administrator does not have proper certification is UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20240314140222
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/03/2024
NARRATIVE
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Continued from 9099-A

The complaint also alleges Staff do not properly lock medications and the med cart is left unattended and unlocked. LPAs observed medications were found to be properly locked and secured and the med cart was locked inside the locked doors of the administrative office; therefore the allegations Staff do not properly lock medications and the med cart is left unattended and unlocked are UNSUBSTANTIATED.

The complaint also alleges that the Administrator does not have proper certification. The Administrator James Sirokman has a valid RCFE Administrator’s Certificate #7014025740, which is effective to 07/01/2025, therefore the allegation the Administrator does not have proper certification is UNSUBSTANTIATED

Finally, the complaint alleges that staff at the facility are not background cleared and have criminal records. A review of documentation show that 10 out of 10 staff have proper background clearance and are associated to the facility, therefore the allegation that staff at the facility are not background cleared and have criminal records is UNSUBSTANTIATED..
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 21-AS-20240314140222
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/03/2024
Section Cited
CCR
87412(c)
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87412(c):Personnel Records. Personnel records shall contain verification of required staff training and orientation, as specified.
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Licensee/Administrator to ensure that all staff receive the required training as specified in Title 22 and that all records are properly recorded in the personnel records of the facility.
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This requirement was not met as evidenced by:
Based on LPA’s inspection on 6/3/2024 of personnel records that did not include proof of staff training which is an immediate risk to the Health & Safety of residents in care.
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 Licensee to submit plan for immediate training and documentation to LPA Nakagawa by close of business 6/4/2024.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5