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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803424
Report Date: 12/17/2024
Date Signed: 12/17/2024 03:55:57 PM

Document Has Been Signed on 12/17/2024 03:55 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:PACE FAIRFIELDFACILITY NUMBER:
486803424
ADMINISTRATOR/
DIRECTOR:		TAFOLLA, ANTHONYFACILITY TYPE:
775
ADDRESS:350 CHADBOURNE RDTELEPHONE:
(707) 427-1731
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY: 75CENSUS: 45DATE:
12/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:40 AM
MET WITH:Anthony Tafolla, DirectorTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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On 12/17/2024 Licensing Program Analysts (LPAs) Frank and Felias conducted an unannounced Annual Required – 1 yr inspection for this facility and met with Program Director, Anthony Tafolla. The facility is licensed by PACE Solano and currently serves 75 clients, 45 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.

LPAs 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 9/2024. Carbon monoxide detector located in hallway connecting all classrooms area was tested and found to be in working order. Alarmtech Security Systems conducted fire safety inspection on 9/2024 for all exits, safety devices including sprinklers, alarms and smoke detectors. Emergency disaster drill were last conducted 9/2024.

Clients were observed to be engaged in various group activities including, discussion, arts & crafts, group movie and other options to choose during classroom hours. Classrooms may also vary depending on client level of care. During the visit, transportation staff and clients had returned from daily outings. Outings include visits to local parks, shopping centers and field trips to local attractions. Facility designates several Direct Support Staff to accompany clients by group and staff to client ratio. Clients observed to have positive relationship with staff continuously engaging and participating with clients. LPAs were 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 and also has a large private outdoor patio located on the side of the building. Toxins and cleaning supplies were secured and inaccessible to clients.

LPAs 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. Water temperature at faucets accessible to clients measured between 106.1 degrees and 116.1 degrees which is within Title 22 regulations requiring water measurements between 105 and 120 degrees F.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE: DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2024
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: PACE FAIRFIELD
FACILITY NUMBER: 486803424
VISIT DATE: 12/17/2024
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...Continued from 809

LPAs conducted a file review of client records and found all items including, program individual plans, personal rights and physician's report to be updated or in order. LPAs conducted sample file review of staff records and found all staff to have sufficient CPR & 1st Aid training completed. Recently hired staff have also completed all onboard training with certification on file.

LPAs also followed up on two incident reports submitted to Community Care Licensing (CCL).

Incident Report 1 and 2: CCL received two incident reports on 12/11/2024. Reports state that while waiting to go home on the transportation bus, Client 1 (C1) was observed hitting Client 2 (C2) repeatedly. Staff Member 1 (S1) intervened while Staff Member 2 (S2) went to get additional staff for assistance. Report states that S1 was verbally aggressive to C1 during the incident. Facility made all appropriate notifications per regulation.

Per conversation with Director, C1 recently had a medication change. They have scheduled a care meeting with C1 and other involved parties to address C1's increase in behaviors. S1 has been placed on administrative leave while an internal investigation is conducted.

LPAs requested the following documents be sent to CCL by DOB 1/17/2025:

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.

Exit interview conducted. Copy of report and Confidential Names (LIC811) discussed and provided to Program Director. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
LIC809 (FAS) - (06/04)
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