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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803662
Report Date: 12/19/2022
Date Signed: 12/19/2022 02:17:24 PM

Document Has Been Signed on 12/19/2022 02:17 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: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: 22DATE:
12/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Licensee, Jim Bernard Garcia
Program Manager, Jeremy Condes
Program Supervisor, Josh Reyes		TIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Peach Hub, The for the purpose of conducting a Required 1 year inspection. LPA met with Licensee, Jim Bernard Garcia, Program Manager, Jeremy Condez and Program Supervisor, Josh Reyes, and was granted access into the facility.

LPA and Program Supervisor toured the 1 story facility. Facility was found to be clean in good repair and at a comfortable temperature. The facility consists of a kitchen, 2 bathrooms, a computer room, library, an activity room, outdoor patio, and a staff office. Bathrooms contained grab bars, hygiene products and continence care products available for client use inside the closet and accessible. Hot water measured at 115 degrees which is within Title 22 regulations of 105 to 120 degrees F in faucets used by clients. Participants typically bring their own lunches and snacks unless there is a party or special occasion. All exits were found to be unobstructed. Medication is stored in a locked cabinet in the staff office. Fire extinguishers were observed to be present with an inspection tag date of October 2022. Carbon Monoxide and Smoke Detectors were tested and found to be operational during the inspection. First Aid kit was inspected and found to be appropriate during the inspection.

LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has sufficient PPE supplies. Facility has been PPE trained (gloves, face masks and how to wash hands).

(Report continued on LIC 809C)
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2022
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: PEACH HUB, THE
FACILITY NUMBER: 486803662
VISIT DATE: 12/19/2022
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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)
Most Recent Fire Alarm System Inspection Report
Fire Sprinkler testing inspection report
Surety Bond
Most up-to-date Liability insurance
Control of Property
Register of clients

No deficiencies were observed or cited during today's Required 1 year inspection. Exit interview was conducted and a copy of this report was emailed to the facility Program Manager due to printer issues.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2022
LIC809 (FAS) - (06/04)
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