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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803662
Report Date: 12/10/2021
Date Signed: 12/10/2021 11:53:20 AM

Document Has Been Signed on 12/10/2021 11:53 AM - 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:PEACH HUB, THEFACILITY NUMBER:
486803662
ADMINISTRATOR:GARCIA, JIM BERNARD PFACILITY TYPE:
775
ADDRESS:380 PITTMAN ROADTELEPHONE:
(707) 389-2403
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY: 45CENSUS: 30DATE:
12/10/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:03 AM
MET WITH:Jim Bernard (Administrator)TIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an annual required inspection based on infection control and met with Administrator, Jim Bernard. The program will be open Monday through Friday from 9:00am to 2:30pm. LPA conducted risk assessment with Administrator at the facility. Upon arrival LPA had their temperature checked and it was documented in an iPad.

LPA/Administrator toured the premises inside and outside, facility consists of a kitchen, 2 bathrooms, computer room, library, activity room in the main area, art room, an outdoor patio with seating and a staff office. The program is not open for in-person classes, there are 30 participants that are receiving alternative services through online activities and staff drop off activity packages including arts and crafts supplies for participants in average once a week. LPA/Administrator reviewed PIN 21-36 ASC, PIN 21-33 ADP and PIN-21-44 ASC. Facility has a centralized sign-in electronic sheet located at loading area where facility documents staff, visitors and eventually participants daily screening. 10 out 11 staff are completely vaccinated; staff who is not vaccinated is still required a weekly surveillance testing. Facility will provide transportation services and they will ensure to screen participants before they can get on the vans as well as facility will screen participants at facility entrance. Administrator agrees to submit a re-entry plan including transportation services to CCL for review prior to participants come back to the day program. Staff was observed wearing a mask while in the facility. All staff have received required training on infection control, but not all the staff have been N95 fit tested yet. Regular maintenance plan includes sanitize every hour or as needed. Facility has automated dispensers to dispense hand sanitizer. Facility has posters that are posted through the facility including bathrooms encouraging participants to wear a mask and maintain social distancing. Facility has sufficient personal protective equipment for staff and participants including face shields, gloves, hand sanitizer and masks. Facility has submitted their Mitigation Plan and it was approved as of 3/25/21. Administrator agreed to notify CCL before re-opening for in-person classes. Administrator agreed to submit the following documents to CCL by 12/24/21: Lease agreement.
No deficiencies cited during today's visit.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 12/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/10/2021
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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