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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800432
Report Date: 12/15/2021
Date Signed: 12/16/2021 03:01:13 PM

Document Has Been Signed on 12/16/2021 03:01 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:PACE-BENICIAFACILITY NUMBER:
486800432
ADMINISTRATOR:TAFOLLA, ANTHONYFACILITY TYPE:
775
ADDRESS:425 MILITARY E STE D, E & HTELEPHONE:
(707) 747-1761
CITY:BENICIASTATE: CAZIP CODE:
94510
CAPACITY: 35CENSUS: 27DATE:
12/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Tony TafollaTIME COMPLETED:
03:33 PM
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct an annual Required-1 year inspection and met with Tony Tafolla, Administrator. The annual inspection is focused on the Infection Control procedures and practices of this Adult Day Program.

The facility is currently providing some in-person Day Program services on Monday, Tuesday, Thursday and Friday and several zoom classes throughout the day. There is currently 27 participants enrolled in the program. Fire Extinguishers were found to be last charged on February 15, 2021.

Upon arrival, LPA observed a screening station at front entrance and a sign-in sheet. Staff took LPA temperature when LPA arrived. Sign-in sheet had a section for visitors to document name and answer COVID-19 screening questionnaire. Staff are screened for COVID-19 (including temperature check) upon arrival to the facility and are also logged into a sign-in sheet. LPA conducted a walk-through of the facility with Administrator and observed COVID-19 precaution postings. Staff clean the facility three times a day and high touched surfaces are disinfected after use. Participants bring their own lunch to Day Program. Classrooms are limited to the number of participants depending on the size of classroom. Facility will follow indoor visitation requirement of verifying and tracking COVID-19 vaccination or verify non-essential visitors have proof of a negative COVID-19 test within 72 hours. Facility staff have completed training on PPE use, infection prevention and have been N95 fit tested. The facility has a 30 day supply of PPE. Staff wore masks during today's visit. The facility has a COVID-19 Mitigation Plan Report on Epidemic Outbreaks specific to COVID-19 .

Exit interview conducted with Tony Tafolla, and a copy of this report will be emailed to facility due to printer problems.
No deficiencies cited during today's inspection
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 12/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2021
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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