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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803424
Report Date: 11/12/2021
Date Signed: 11/12/2021 07:36:28 PM

Document Has Been Signed on 11/12/2021 07:36 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:PACE FAIRFIELDFACILITY NUMBER:
486803424
ADMINISTRATOR:SWEARENGIN, EMILYFACILITY TYPE:
775
ADDRESS:350 CHADBOURNE RDTELEPHONE:
(707) 427-1731
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY: 75CENSUS: 15DATE:
11/12/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Emily Swearengin - AdministratorTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Fernandes-Goes conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and was welcome by program administrator Emily Swearengin. There were 15 clients present at the facility. Facility has different activities been offered through out of the day including outings and Zoom.

LPA toured the facility on 11/12/2021 with program administrator Emily S. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. LPA toured building and grounds, day activity rooms, kitchen, and restrooms. Smoke detectors and sprinklers system are hard wired – audible and visual alarms. Program Manager state that hard wired smoke detectors and sprinklers system were last inspected on 2021, however; facility will be submitting proof of test. Fire extinguishers are fully charged with last inspection on 09/2021. Clients most of the time uses their own transportation. Facility vans were not at the facility at the time of this visit. Toxins, chemicals and hazardous items were safely stored in a locked storage closet in the hallway. Bathrooms were all equipped with soap dispensers and individual paper towels. There is a sufficient supply of sanitary products on hand. Hot water temperature measured between 133.5 degrees F & 137.6 degrees F following out of Title 22 acceptable regulation of 105 to 120 degrees F in 2 out of 2 client's restroom faucets (see LIC 809-D). Clients provide their own snacks and lunches but program will supply food for special occasions. There is two refrigerators available for client & staff food. Facility handles P&I. Facility has PPE supply stored in the facility storage and administrator's office. Staff have had all PPE training required on file and facility still working towards acquiring N-95 fit testing for staff. In addition, LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Disaster Drills have been conducted monthly with the last dated 10/28/2021.

Continue LIC 809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE: DATE: 11/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/12/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 FAIRFIELD
FACILITY NUMBER: 486803424
VISIT DATE: 11/12/2021
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LPA reviewed Pace Fairfield employee summary evaluation from Guardian dates 11/9/21 & 11/12/21 and learned that staff S1 was hired on 4/16/2018 and associated to the facility on 5/4/2018 and disassociated on 9/28/2021. (see copies) The facility program administrator Emily S confirmed that staff has been working at the facility M-F 8 AM to 3 PM on 4/16/2018. Facility provided LPA with copies of LIC 508, LIC 9182, and ID at the end of today's visit for staff S1's association.

Civil penalties are assessed at the rate of $100 per day per employee in accordance with Title 22 Regulations # 82019(e). Today’s assessment of $500 is for Staff 1 (S1)

Appeal of Rights Given.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.


Department is requesting the following to be submitted by 11/19/2021 to CCL:
Copy of Admissions Agreement
LIC 400 Affidavit Regarding Client
Articles of CIncorporation or Organization, Constitution and Bylaws
Copy of Lease
LIC 308 Designation of Responsibility
Job Prescriptions
LIC 500 Personnel Report
LIC 402 Surety Bond
Theft & Loss Policy
Copy of Fire Inspection
LIC 610 Emergency Preparedness
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2021
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Document Has Been Signed on 11/12/2021 07:36 PM - It Cannot Be Edited


Created By: Carla Fernandes-Goes On 11/12/2021 at 12:29 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: PACE FAIRFIELD
FACILITY NUMBER: 486803424

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/12/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 2 out of 2 client's restroom faucets which poses an immediate health, safety or personal rights risk to persons in care. During this visit on 11/12/21 hotwater temperature at client's restrooms faucets measured between 133.5 degrees F and 137.6 degrees F.
POC Due Date: 11/13/2021
Plan of Correction
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Facility to ensure that hot water temperature stays within Title 22 Regulations of not less than 105 degree F and not more than 120 degree F. Facility agrees to adjust hot water temperature by 11/13/2021 and submit a self certification LIC 9098 that hotwater has been adjusted and a 5 day hotwater log by 12/5/2021.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:
DATE: 11/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/12/2021


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 11/12/2021 07:36 PM - It Cannot Be Edited


Created By: Carla Fernandes-Goes On 11/12/2021 at 02:03 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: PACE FAIRFIELD
FACILITY NUMBER: 486803424

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/12/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type A
Section Cited
CCR
82019(e)
Criminal Record Clearance
(e) Prior to working, residing or volunteering in a licensed day program, all individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall do the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation,interview, and record review, the licensee did not comply with the section cited above in 1] out of 9 staff associated to the facility which poses an immediate health, safety or personal rights risk to persons in care.On11/12/21 LPA learned that staff S1 has been working in the facility since 4/16/2018 and according with records on Guardian is fingerprint cleared and not associated to facility at this time.
POC Due Date: 11/13/2021
Plan of Correction
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Facility administrator understands that staff must be fingerprint cleared & associated to the facility before working at facility. Facility administrator to submit a self certification that all staff working at the facility are fingerprint cleared & associated to facility before starting to work which should be submitted to Department by POC date of 10/13/21 is order to clear this citation. (civil penalty) Facility provided forms for association at the end of the visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:
DATE: 11/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/12/2021


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