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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801825
Report Date: 02/10/2024
Date Signed: 02/10/2024 03:14:42 PM


Document Has Been Signed on 02/10/2024 03:14 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: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: 4DATE:
02/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:CaregiverTIME COMPLETED:
03:02 PM
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On 2/10/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to conduct a required 1-year annual inspection. LPA met with Amalia Diloy and explained the purpose of the visit. Staff contacted Administrator who informed LPA she was out of town. Administrator stated staff are able to conduct inspection with LPA.

Today's census is four residents in care, one on hospice service. Facility is in compliance to licensure.

LPA and Staff conducted a tour of the interior and exterior of the facility. Areas toured included but not limited to: three resident bedrooms, staff room, bathroom, kitchen, garage/laundry room, backyard and the common areas. LPA observed the facility to be at a comfortable temperature of 70*. LPA observed sharps, medications and toxins to be locked and secured. LPA observed the facility to have ample supply of linens, perishable and non-perishable foods. LPA observed the posted Administrator Certificate to be expired, but observed Administrator to be on CCLD pending list. LPA was informed there are no current concerns at the facility. In areas toured, no immediate health, safety or personal rights violation was observed.

File review conducted. LPA completed the full care inspection tool and found the facility to be in compliance to California Code Regulation, Title 22. No deficiencies cited.

At this time, LPA is requesting a copy of LIC 500 and liability insurance to be emailed to LPA Yang by Friday February 16, 2024.

Exit interview conducted and a copy of the report was emailed to Administrator.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (279) 300-5157
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 02/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2024
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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