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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 480110049
Report Date: 07/22/2022
Date Signed: 07/22/2022 11:04:14 AM

Document Has Been Signed on 07/22/2022 11:04 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:PACE-GEORGIAFACILITY NUMBER:
480110049
ADMINISTRATOR:TAFOLLA, ANTHONYFACILITY TYPE:
775
ADDRESS:1330 GEORGIA STTELEPHONE:
(707) 557-0794
CITY:VALLEJOSTATE: CAZIP CODE:
94590
CAPACITY: 90CENSUS: 80DATE:
07/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Program Director, Brittany BerringerTIME COMPLETED:
11:10 AM
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Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. Infection Control inspection for this facility and met with Program Director, Brittany Berringer and Program Coordinator, Laurel Stickel. The facility is licensed by PACE Solano and currently serves 80 clients, 20 of which were at the facility at the time of visit. The facility is currently conducting a hybrid service program in which two groups of clients attend program on staggered days throughout the week. The first group participates in-person on Monday and Tuesday with the second group participating on Thursday and Friday. Both groups also attend program on alternating Wednesdays and have access to online classes and activities on days they are not attending in-person program.

Clients appear to be engaged in group activities with proper social distancing in place. LPA was informed of Clients currently provide their own meals with group outings away from the facility currently on hold. Facility continues to hold outdoor activities and gardening in the courtyard. Sharps are all stored in a locked cabinet located in the kitchen. Toxins and cleaning supplies are stored in a designated cleaning supply closet inaccessible to clients. Facility has contracted with R&D Transportation Services who conduct symptom and temperature checks upon picking up clients. Clients who do not utilize R&D Transportation Services will be transported by client home or facility and also conduct symptom and temperature checks.

LPA arrived at the facility and had temperature checked and logged. LPA continued with a tour of the facility with staff; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire extinguishers were found to be last charged January 28, 2022. In addition, smoke and carbon monoxide detectors tested and found to be in working order. LPA found that the facility annual fire inspection had last been completed on 3/6/2020. Program Director will be contacting Vallejo Fire Department and request for an updated inspection.

Continue onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2022
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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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: PACE-GEORGIA
FACILITY NUMBER: 480110049
VISIT DATE: 07/22/2022
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Water temperature at faucets accessible to clients measured between 99.5 and 102.2 degrees F which is not within Title 22 regulations requiring water measurements between 105 and 120 degrees F. LPA was informed that water temperatures are measured and recorded monthly and staff are aware of the water temperature requirements. LPA issued Technical Violation and requested for Program Director to complete a 7 day water temperature log and provide to CCLD for corrections.

Facility has submitted an Infection Control Plan for review. Posters are located at the facility entrance, common areas and each classroom indicating COVID protocols and mitigation. Facility has a station at main entrance with a sign in sheet, hand sanitizer and other items designated for clients and staff. Staff and clients are also screened on a daily basis.

LPA requested the following documents be sent to CCL by COB 7/29/2022:

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

No deficiencies cited during today's visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2022
LIC809 (FAS) - (06/04)
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