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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803305
Report Date: 09/29/2023
Date Signed: 09/29/2023 01:04:15 PM

Document Has Been Signed on 09/29/2023 01:04 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: 60DATE:
09/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Britanny McEwenTIME COMPLETED:
01:15 PM
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On 9/29/2023 Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr inspection for this facility and met with Program Director, Brittany McEwen. The facility is licensed by PACE Solano and currently serves 60 clients, 43 of which were at the facility at the time of visit. The facility is currently conducting partial in-person service program with hybrid options available to some clients. The facility runs on staggered scheduling.

LPA arrived at the facility and completed sign in record. LPA continued with a tour of the facility with Director; 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 August 29, 2023. Carbon monoxide detector located in main common area was tested and found to be in working order. Fairfield Fire Department conducted fire safety inspection on 10/10/2022 for all exits, safety devices including sprinklers, alarms and smoke and carbon monoxide detectors.

Clients were observed to be engaged in various group activities including, discussion, crafts, bingo and other options to choose during classroom hours. During the visit, clients attended outings including visits to local parks and shopping centers. Facility designates several Direct Support Staff to accompany clients by group. Clients observed to have positive relationship with staff continuously engaging and participating with clients. LPA was informed that clients currently provide their own meals with snacks provided throughout the day. Facility also offers scheduled lunch outings scheduled throughout the month. Facility primarily holds outdoor activities during outings but also has a large outdoor parking lot area located in the rear of the building. Toxins, cleaning supplies and other potentially dangerous items are stored in a designated cleaning supply closet inaccessible to clients. LPA also conducted a spot mediation check for clients and found all administration and prescription input records to be in order. Medications were located in designated drawers and all found to be secured in staff office. Facility has contracted with R&D Transportation Services.
Continue onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2023
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: 09/29/2023
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Water temperature at faucets accessible to clients measured between 115.5 and 116.2 degrees F which is within Title 22 regulations requiring water measurements between 105 and 120 degrees F. LPA conducted a file review of client records and found all items including, program individual plans, personal rights and physician's report o be updated or in order. LPA conducted sample file review of staff records and found all staff to have sufficient CPR & 1st Aid certification on file. Recently hired staff have also completed all onboard training with certification on file.

LPA requested the following documents be sent to CCL by COB 10/29/2023:

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

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

DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023
LIC809 (FAS) - (06/04)
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