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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803305
Report Date: 09/20/2022
Date Signed: 09/20/2022 01:13:00 PM

Document Has Been Signed on 09/20/2022 01:13 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:PACE WINERY SQUAREFACILITY NUMBER:
486803305
ADMINISTRATOR:BRITTANY MCEWENFACILITY TYPE:
775
ADDRESS:1955 W TEXAS ST STE 190TELEPHONE:
(707) 426-6932
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 75CENSUS: 16DATE:
09/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Program Manager, Brittany McEwen
Program Manager, Terri Roach		TIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Pace Winery Square for the purpose of conducting a Required 1 year inspection. LPA was met at the door by Program Manager, Brittany McEwen, and was granted access into the facility. Also participating in the Required 1 year inspection was Program Manager, Terri Roach.

LPA toured the facility with Program Manager, Brittany McEwen. Facility is a one floor building. LPA observed the facility to be clean and at a comfortable temperature with all exits free from obstruction. Hot water temperature measured at 110 degrees F in 5 of 5 client bathrooms. Smoke Detector and Carbon Monoxide Detector sound directly to the fire station and were last tested on March 28, 2022. Emergency Disaster Drill was conducted on August 29, 2022. First Aid kit was appropriate during the inspection. The facility has a phone line designated for client use. There is a supply of personal hygiene products located with the PPE storage. Personnel records and client records are stored at the facility office area. The first level floor includes kitchen equipped with 4 refrigerators; art, drawing & painting room, conference room, activity rooms, storage, offices and client's & staff bathrooms. Activities are pre-planned and reflect on the Activity Board. Client & staff records, medication, first aid supplies, and toxins are locked and inaccessible to clients in care. Clients will bring their own food and food will be provided for plan celebrations. Motor vehicle to be used to transport clients inspected to ensure safe operating condition and will be offered if needed. California Highway Patrol (CHP) inspects the vehicles annually with the last inspection on April 27, 2022.

LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has PPE in the closet closest to the 5 bathrooms.

(Report continued on LIC 809C)
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2022
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 WINERY SQUARE
FACILITY NUMBER: 486803305
VISIT DATE: 09/20/2022
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LPA requested the following documents to be sent:

LIC 500- Personnel Report
LIC 308- Designation of Responsibility
LIC 309- Administrative Organization
LIC 400- Affidavit regarding Client Cash Resources
Updated facility sketch
Updated Emergency Disaster Plan (LIC 610D)
Surety Bond
Most up-to-date Liability insurance
Control of Property
Register of residents

No deficiencies were observed or cited during today's Required 1- Year inspection. Exit interview was conducted and a copy of this report was given to the facility Program Manager, Brittany McEwen.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022
LIC809 (FAS) - (06/04)
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