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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
486801825
Report Date:
06/28/2022
Date Signed:
06/28/2022 02:28:47 PM
Document Has Been Signed on
06/28/2022 02:28 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:
WARD RESIDENTIAL CARE HOME II
FACILITY NUMBER:
486801825
ADMINISTRATOR:
POQUIZ, EUGENE & ALICIA
FACILITY TYPE:
740
ADDRESS:
125 BRET HARTE WAY
TELEPHONE:
(707) 648-2760
CITY:
VALLEJO
STATE:
CA
ZIP CODE:
94589
CAPACITY:
6
CENSUS:
6
DATE:
06/28/2022
TYPE OF VISIT:
Case Management - Incident
UNANNOUNCED
TIME BEGAN:
01:45 PM
MET WITH:
Amalia Diloy, Lead Staff
TIME COMPLETED:
02:35 PM
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On 6/28/2022 Licensing Program Analyst (LPA) Tobola conducted an unannounced Case Management Visit for the purpose of following up on an self-reported incident in which resident (R1) was admitted to the facility due to emergency placement from North Bay Regional Center. LPA made observations and gathered statements. R1 was reported to have demonstrated physically aggressive acts towards staff S1 & S2. LPA informed that R1 had struck S1 on the arms and S2 on the chest while staff would assist R1 in the restroom. Licensee and staff were not aware of R1's behaviors due to no health or care related information provided to the Licensee.
Staff are reported to be okay with no serious injuries. Licensee was contacted by phone and report provided.
No deficiencies cited during today's visit.
SUPERVISOR'S NAME:
Kimberley Mota
TELEPHONE:
(707) 588-5051
LICENSING EVALUATOR NAME:
Dominic Tobola
TELEPHONE:
(707) 588-5081
LICENSING EVALUATOR SIGNATURE:
DATE:
06/28/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/28/2022
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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