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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803305
Report Date: 09/22/2021
Date Signed: 09/22/2021 11:32:52 AM

Document Has Been Signed on 09/22/2021 11:32 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:PACE WINERY SQUAREFACILITY NUMBER:
486803305
ADMINISTRATOR:TERRI ROACHFACILITY TYPE:
775
ADDRESS:1955 W TEXAS ST STE 190TELEPHONE:
(707) 426-6932
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 75CENSUS: 63DATE:
09/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Terri Roach, AdministratorTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Lopez arrived unannounced to conduct a Required-1 year inspection and met with Terri Roach, Administrator. LPA Lopez called facility to conduct a risk assessment for COVID-19 prior to visit and spoke with Administrator. The Required-1 year 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 for 22 clients who attend throughout the week, except on Wednesday's. All clients have the option to attend program virtually. During visit, LPA observed a Zoom class with multiple clients present. Some clients who attend in person also go to job sites and also go with staff for walks. Staff have backpacks that they have to take when going on walks with clients. The backpacks have PPE which includes thermometers, masks, hand sanitizers and a screening sheet available for clients.

Upon arrival, LPA observed a screening station at front entrance of facility which had hand sanitizer, a thermometer, and a sign-in sheet. Administrator took LPA temperature when LPA arrived. 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 once a day and high touched surfaces are disinfected twice a day. LPA found Fire Extinguishers to be last serviced and charged on September 14, 2021.

The facility has a 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 which was reviewed by the California Department of Social Services.

Exit interview conducted with Terri Roach, whose signature on this document confirms receipt.

No deficiencies cited during today's inspection.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Karen Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 09/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/22/2021
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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