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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800432
Report Date: 01/24/2024
Date Signed: 01/24/2024 03:43:01 PM

Document Has Been Signed on 01/24/2024 03:43 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
SANTA ROSA RO, 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: 15DATE:
01/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Tony TafollaTIME COMPLETED:
04:00 PM
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On 01/24/2024 02:00 PM Licensing Program Analyst (LPA) Sarah Benson arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with Tony Tafollia Program Manager and explained the purpose of the visit.

LPA Benson and administrator toured the facility together to ensure the health and safety of clients in care. Areas toured include but are not limited to common areas, kitchen and storage area. In the areas toured no immediate health, safety, or personal rights violations were observed. Staff and resident files were reviewed. Medications were also reviewed.



The common area was clean and in good repair. The bathrooms were clean and in good repair. The kitchen was clean and in good repair. Cooking/dining equipment and utensils were present. Medication is locked in a locked closet.

The facility was observed to be at a comfortable temperature. First aid kit fully stocked and ready for emergency use. Fire extinguisher fully charged. Smoke detectors are all operational. Hot water temperature measured within required Title 22 regulations of 105 degrees F and 120 degrees F. All employees requiring background checks are cleared. There is a schedule of activities Planned for the clients. All required postings are displayed within facility.

No pools/bodies of water are on the premises. No firearms are on premises. The last disaster drill was conducted and documented on 12-20-2023 , the facility has been conducting drills every month.

The facility is in compliance. No deficiencies are being cited as a result of today’s inspection.



Exit interview conducted and copy of the report was provided to administrator.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2024
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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