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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801146
Report Date: 06/27/2022
Date Signed: 06/27/2022 12:53:09 PM

Document Has Been Signed on 06/27/2022 12:53 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:PRIDE INDUSTRIESFACILITY NUMBER:
486801146
ADMINISTRATOR:DARELYN PAZDELFACILITY TYPE:
775
ADDRESS:2339 COURAGE DRIVE, STE DTELEPHONE:
(707) 399-3601
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 30CENSUS: 24DATE:
06/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Rita Morrison, Rehabilitation Services Manager TIME COMPLETED:
01:04 PM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct an Annual Required - 1 Year inspection and met with Rehabilitation Services Manager Rita Morrison and Administrator Darelyn Pazdel was also present. The annual inspection is focused on the Infection Control procedures and practices of this Adult Day Program. All staff wore masks during this visit. Facility has a screening station with sign-in sheet and COVID questionnaire. LPA was screened for COVID-19 symptoms and LPA's temperature was taken upon arrival. Fire extinguisher was charged and serviced 01/31/2022. LPA conducted a walk-through of the facility and all exits were unobstructed. Pride Industries is currently providing in-person services Monday through Friday. The facility also provides alternative services such as various zoom classes, activity packets, and community outings. LPA observed COVID-19 precaution postings; soap & paper towels were available. Staff clean the facility daily. The facility does not handle client cash resources or medication. The facility has a supply of PPE including gloves, hand sanitizer, N-95 respirators and surgical masks. Staff and participant's temperatures are taken upon arrival and documented. LPA verified staff vaccination records during this visit.
LPA & Administrator discussed reporting requirements and first aid certifications for staff.

LPA requested the following updated forms to be submitted to Community Care Licensing by 07/18/2022:
    · LIC 308 Designation of Facility Responsibility (1 person per form)
    · LIC 500 Personnel Report
    · LIC 400 Affidavit Regarding Client/Resident Cash Resources (indicate if not handling cash for clients)
    · LIC 610D Emergency Disaster Plan
    · LIC 9020 Register of Facility clients
    · Copy of current Lease/Rental Agreement or Property Tax document showing control of property.
    ** Reminder Facility Infection Control Plan is due 6/30/2022
Exit interview conducted with Rita Morrison, whose signature on this document confirms receipt.
**No deficiencies cited during this inspection
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2022
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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