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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800432
Report Date: 11/22/2022
Date Signed: 11/22/2022 11:22:50 AM

Document Has Been Signed on 11/22/2022 11:22 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-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: 18DATE:
11/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:53 AM
MET WITH:Tony Tafolla, AdministratorTIME 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, Tony Tafolla. The facility is licensed by PACE Solano and currently serves 27 clients, 18 of which were at the facility at the time of visit. The facility is currently serving near full capacity Monday through Friday with several clients also being served remotely.

Clients appear to be engaged in group activities engaged with staff and other clients. LPA was informed that clients primarily provide their own meals with additional cooking activities and holiday's celebrations. Facility continues to hold both indoor and outdoor activities including walks, gardening and job sites for clients. 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. During the inspection LPA observed one of the locked cabinets underneath the kitchen sink to be have a loose lock. All staff were present in the area and potential toxins were inaccessible. LPA issued Technical Violation and facility agreed to provide proof of corrections to ensure repairs. Facility has contracted with R&D Transportation Services who conduct symptom and temperature checks upon picking up clients.

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 February 17, 2022. Facility had completed Fire Inspection for building sprinkler, smoke and carbon monoxide detectors. Program Director will be contacting Benicia Fire Department and request for a copy of the inspection. Continue onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2022
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-BENICIA
FACILITY NUMBER: 486800432
VISIT DATE: 11/22/2022
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Water temperature at faucets accessible to clients measured at 114.0 degrees F which is within Title 22 regulations requiring water measurements between 105 and 120 degrees F. LPA was informed that water temperatures are measured and recorded weekly and staff are aware of the water temperature requirements. LPA conducted a sample file review for staff 1st Aid & CPR Training and found all staff to have updated training on file.

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 prior to the entry into the facility with testing completed based on observed change of condition or symptoms.

LPA requested the following documents be sent to CCL by COB 11/29/2022:

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

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

DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022
LIC809 (FAS) - (06/04)
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