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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
486803984
Report Date:
07/12/2024
Date Signed:
07/12/2024 01:27:35 PM
Document Has Been Signed on
07/12/2024 01:27 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 NORTH
FACILITY NUMBER:
486803984
ADMINISTRATOR:
SIROKMAN, JAMES
FACILITY TYPE:
740
ADDRESS:
5073 VICTOR LANE
TELEPHONE:
(949) 439-2836
CITY:
VACAVILLE
STATE:
CA
ZIP CODE:
95688
CAPACITY:
11
CENSUS:
DATE:
07/12/2024
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
12:30 PM
MET WITH:
Jim Sirokman, Administrator
TIME COMPLETED:
01:32 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced
for the purpose of conducting a Case Management visit to clear the POC from the visit on 06/03/2024.
LPA met with administrator James Sirokman and discussed the corrections made. LPA did a review of three (3) employee files and found that the training records for those employees were in place and complete. Administrator has completed the requirements for clearing the Plan of Correction.
No deficiencies cited on this visit.
Exit interview conducted with J. Sirokman and copy of this report left on site.
SUPERVISOR'S NAME:
Kimberley Mota
TELEPHONE:
(707) 588-5051
LICENSING EVALUATOR NAME:
Jill Nakagawa
TELEPHONE:
707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE:
07/12/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/12/2024
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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