<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 480110049
Report Date: 07/06/2023
Date Signed: 07/06/2023 02:31:44 PM

Document Has Been Signed on 07/06/2023 02:31 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:PACE-GEORGIAFACILITY NUMBER:
480110049
ADMINISTRATOR:TAFOLLA, ANTHONYFACILITY TYPE:
775
ADDRESS:1330 GEORGIA STTELEPHONE:
(707) 557-0794
CITY:VALLEJOSTATE: CAZIP CODE:
94590
CAPACITY: 90CENSUS: 75DATE:
07/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Brittany Berringer, Program DirectorTIME COMPLETED:
02:40 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 7/6/2023, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. Inspection for this facility and met with Administrator, Sarah Mathis and Program Director, Brittany Berringer. The facility is licensed by PACE Solano and currently serves 75 clients, 38 of which were at the facility at the time of visit. The facility is currently conducting both in-person and online courses for clients enrolled with multiple participation scheduling options available weekly, Monday through Friday.

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 17, 2023. In addition, smoke and carbon monoxide detectors throughout the facility were tested and found to be in working order. Emergency disaster drills covering fire evacuations and earthquake safety protocols are interchanged and conducted on a monthly basis.

Clients appear to be engaged in group activities with proper social distancing in place. LPA was informed that clients currently provide their own meals with additional snacks readily available. Facility continues to hold outdoor activities in the courtyard with re-continuing client outings. Each activity room is equipped with activity supplies and secured storages. Sharps are all stored in a locked cabinet located in the kitchen. Toxins and cleaning supplies are stored in a designated cleaning supply closets inaccessible to clients. Facility has contracted with R&D Transportation Services who conduct frequent vehicle inspections and confirming maintenance and are equipped with 1st Aid Kits.

Continue onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 07/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/06/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: 07/06/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Water temperature at faucets accessible to clients measured between 107.9 and 108.5 degrees F which is within Title 22 regulations requiring water measurements between 105 and 120 degrees F. LPA conducted a sample review of staff files and found all staff to have current 1st Aid & CPR certification and annual training documented. In addition, LPA conducted a sample review of client files and found all documents including PACE Individual Program Plans to be updated and documented.

LPA requested the following documents be sent to CCL by COB 8/6/2022:

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: 07/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2