486803424-11-19-2025-21-AS-ADEZ-DNKRV4-20251119122055

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803424
Report Date: 11/19/2025
Date Signed: 11/19/2025 12:21:14 PM

Document Has Been Signed on 11/19/2025 12:21 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 FAIRFIELD		FACILITY NUMBER:	486803424
ADMINISTRATOR/ DIRECTOR:	TAFOLLA, ANTHONY		FACILITY TYPE:	775
ADDRESS:	350 CHADBOURNE RD		TELEPHONE:	(707) 427-1731
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94534
CAPACITY: 75		CENSUS: 57	DATE:	11/19/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:15 AM
MET WITH:	Program Director, Doniese Roberts		TIME VISIT/ INSPECTION COMPLETED:	12:46 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 11/19/2025 at approximately 09:15AM, Licensing Program Analyst (LPA) Ali Deniz arrived unannounced to conduct 1-Year Required visit of this licensed Adult Day Program (ADP). LPA was greeted by Program Director, Doniese Roberts. The facility is licensed by PACE Solano and currently has capacity of 75 clients with approved fire clearance for 45 ambulatory and 30 non-ambulatory clients, which 57 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. Upon arrival, LPA was informed that there were 24 staff members on-site. Facility is a 1 story building with 6 classrooms, 4 restrooms, offices, a kitchen, and common spaces. At approximately 10:15AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. At approximately 10:45 AM, LPA and Program Director conducted a tour of the building and grounds, which were observed to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. All notices that are required to be posted have been posted. LPA observed activity supplies for clients use. Clients bring their own food with them. Facility kitchen, refrigerators and freezers were clean, and food was stored properly. Toxins are stored in a locked housekeeping room. Water temperature measured 113.6 degrees F and 112.1 degrees F which is within regulation between 105- and 120-degrees F at faucets accessible to clients. Fire extinguishers were found to be last charged on 9/25/2025. Carbon monoxide detector located in hallway connecting all classrooms area was inspected by City of Fairfield Fire Department on 3/26/2025 and found to be in working order. Alarmtech Security Systems conducted fire safety inspection on 2/28/2025 for all exits, safety devices including sprinklers, alarms and smoke detectors. There was enough lighting in all common areas, classrooms, and hallways. Medication is centrally stored and secure in the medication room. Continued on LIC809-C...

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Ali Deniz
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/19/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 11/19/2025

NARRATIVE

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Continued from LIC809...

Clients were observed to be engaged in various group activities including, discussion, arts & crafts, group movie and other options to choose during classroom hours at the time of this visit.

At approximately 11:25AM, LPA reviewed 5 clients records and found 5 of 5 clients have current care plans, signed admission agreements, and physician's report on file. Medication records are thorough and contained physician's orders for each resident.

At approximately 12:05PM, LPA reviewed 5 staff records. 5 of 5 records did contain documentation of completed training records as required. Evidence of current first aid and CPR training were current. LPA was presented with proof of current CPR & 1^st Aid certification for the staff. Facility conducted and documented a disaster drill on 10/16/2025.

P&I's are kept on a locked filed cabinet in the facility office; facility responsible for five client’s P&I and money; facility had P& I ledgers available during the visit. P&I money not comingle and ledgers are current at this time.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by due date of 11/30/2025:
- LIC 9020 Register of Facility Client’s/Resident’s
- Copy/Proof of Updated Certificate of Liability Insurance

No deficiencies were observed in the areas inspected, No citations were issued during today’s visit.

Exit interview conducted. Copy of report provided to Director. Signature on form confirms receipt of documents.

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Ali Deniz
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/19/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2025

LIC809 (FAS) - (06/04)

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