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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801825
Report Date: 12/28/2021
Date Signed: 02/03/2022 09:26:05 AM

Document Has Been Signed on 02/03/2022 09:26 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:WARD RESIDENTIAL CARE HOME IIFACILITY NUMBER:
486801825
ADMINISTRATOR:POQUIZ, EUGENE & ALICIAFACILITY TYPE:
740
ADDRESS:125 BRET HARTE WAYTELEPHONE:
(707) 648-2760
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 6CENSUS: 6DATE:
12/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH: Care Giver, Amy DiloyTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Ward Residential Care Home II for the purpose of conducting a Required-1 year inspection. LPA was greeted at the door by Care Giver, Amy Diloy, and was granted access into the facility.

LPA toured and inspected the building and grounds, which was found to be unobstructed, clean and in good repair. There were no firearms, weapons, or bodies of water in the home. The amount of fresh and non-perishable foods were within regulation. There is a sufficient amount of hygiene products and linens for residents in care. Water temperature was tested during inspection and found to be at an appropriate temperature between 105 to 120 degrees. All resident's bathrooms contained necessary grab bars and non-slip floors/mats. The fire extinguisher was charged and serviced July 2021. There is a total of 5 smoke detectors and 1 carbon monoxide detector, which were all tested during inspection and observed to be operable. LPA observed facility's auditory alarms were operable. LPA observed the staff screen door off track. LPA issued an LIC 9102 to have the screen door fixed and put back on track. Staff have valid CPR & First Aid certifications. First aid kit was found to be appropriate during the inspection. LPA requested Facility to update the following documents: Emergency Disaster Plan. LPA also requested the following documents to be sent to the Regional Office, LIC 309, LIC 400, LIC 308, updated facility sketch, LIC 500 and updated liability insurance.

LPAs advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has not been N95 Fit tested. PPE is not sufficient in the facility. LPA advised to have PPE filled immediately. Staff has had training in PPE use.

No deficiencies were cited during today's Required 1- Year inspection. Exit interview was conducted and a copy of this report was emailed to the Facility Administrator.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 12/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/28/2021
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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