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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803424
Report Date: 10/31/2022
Date Signed: 10/31/2022 02:36:20 PM

Document Has Been Signed on 10/31/2022 02:36 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:PACE FAIRFIELDFACILITY NUMBER:
486803424
ADMINISTRATOR:TERRY ROACHFACILITY TYPE:
775
ADDRESS:350 CHADBOURNE RDTELEPHONE:
(707) 427-1731
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY: 75CENSUS: 22DATE:
10/31/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Program Manager, Terri RoachTIME COMPLETED:
02:50 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived at Pace Fairfield unannounced for the purpose of conducting a Required 1 Year inspection. LPA was greeted at the door by, Program Manager, Terri Roach, and was granted access into the facility.

LPA toured the facility with Program Manager, Terry Roach. Facility is a one floor building. LPA observed the facility to be clean and at a comfortable temperature with all exits free from obstruction. There are four restrooms on this floor. Hot water temperature measured at 116 degrees within Title 22 regulation of 105-120 degrees. Smoke Detector and Carbon Monoxide Detector sound directly to the fire station and were last tested on October 14, 2022. Emergency Disaster Drill was conducted in October 2022. Fire extinguisher was last serviced on August 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. Personnel records and client records are stored at the facility office area. The 1st level floor includes kitchen equipped with a small refrigerator; art, drawing & painting room, conference room, activity rooms, storage, offices and client's & staff bathrooms. Activities are pre-planned & clients will opt where to go once at the facility. LPA observed an activity menu posted in the lobby of the facility. 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 office. (Report continued on LIC 809C)
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 10/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2022
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 FAIRFIELD
FACILITY NUMBER: 486803424
VISIT DATE: 10/31/2022
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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, Terry Roach.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2022
LIC809 (FAS) - (06/04)
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