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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 480110049
Report Date: 06/20/2024
Date Signed: 07/09/2024 11:19:46 AM

Document Has Been Signed on 07/09/2024 11:19 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/
DIRECTOR:		TERRI ROACHFACILITY TYPE:
775
ADDRESS:1330 GEORGIA STTELEPHONE:
(707) 557-0794
CITY:VALLEJOSTATE: CAZIP CODE:
94590
CAPACITY: 90CENSUS: 64DATE:
06/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Terri Roach, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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On 6/20/2024, Licensing Program Analyst (LPA) Jill Nakagawa conducted an unannounced Annual Required – 1 yr. Inspection for this facility and met with Administrator, Terri Roach. The facility is licensed by PACE Solano and currently serves 64 clients, 43 of which were at the facility at the time of visit. There were 25 staff at the time of inspection. 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 and was granted access to the facility by Administrator Terri Roach. A tour of the facility found all exits free from obstruction, and all 6 classrooms to be clean and a comfortable temperature of 73 degrees F. Fire extinguishers were found to be last charged January 18, 2024, and were fully charged and operational. In addition, smoke and carbon monoxide detectors throughout the facility were tested and found to be in working order. The fire department conducted inspections on 9/20/2023. Emergency disaster drills covering fire evacuations and earthquake safety protocols are interchanged and conducted on a monthly basis; the last one conducted on 05/09/2024.

LPA was informed that clients currently provide their own meals with additional snacks readily available. Facility continues to conduct client outings. Each classroom 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 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 First Aid Kits.
Continued on 809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2024
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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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: 06/20/2024
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Continued from 809

Water temperature at faucets accessible to clients measured between 105 and 120 degrees F which is within Title 22 regulations.

LPA conducted a sample review of 5 staff files and found all staff to have current First Aid & CPR certification and annual training documented. In addition, LPA conducted a sample review of 5 client files and found all documents including PACE Individual Program Plans to be updated and documented.

No deficiencies found at the time of inspection.
No citations issued.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024
LIC809 (FAS) - (06/04)
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