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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803937
Report Date: 03/15/2021
Date Signed: 03/16/2021 08:26:38 AM

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 IFACILITY NUMBER:
486803937
ADMINISTRATOR:POQUIZ, ALICIAFACILITY TYPE:
740
ADDRESS:110 WARD CTTELEPHONE:
(707) 643-6331
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY:6CENSUS: 5DATE:
03/15/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Applicant, Alicia PoquizTIME COMPLETED:
12:30 PM
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Licensing Program Analyst Willis conducted the Pre-licensing Inspection and Component III via video conferencing due to Covid-19 precautions with Applicant, Alicia Poquiz.

LPA/Applicant toured the inside of the facility and grounds via video conference. Facility is a one-story residence with four bedrooms, two bathrooms, a family room, a living room and a kitchen. The three bedrooms designated for residents are shared. Facility bedrooms have all personal accommodations. Residents bedrooms had the required furnishings, such as a dresser, nightstand, lamp and bed linens. Bathrooms showers have nonskid mats and grab bars for safety. Facility received an approved fire clearance November 10, 2020 that allows for four non-ambulatory residents and two ambulatory. LPA observed required postings (LTCO, CCL Complaint poster, visitor policy, employee rights and personal rights). COVID-19 required postings were not observed. Applicant will post Covid-19 posters and send a picture of postings to LPA. All appliances in the kitchen were working properly. Applicant showed some contents of their First Aid Kit.. Emergency Lighting for power outages was observed in bedrooms and hallway. Applicant tested the water temperature at 118 degrees F which is within regulation of 105 & 120 degrees F.

Facility will lock centrally stored medications in a cabinet in the kitchen. LPA observed that cleaning supplies and toxins are locked in a cabinet under the kitchen sink and in a locked cabinet in the garage.Perishable and non-perishable foods observed per regulation. Facility has space indoors and outdoors for resident activities.

Component III is weaved as Applicant is a current Licensee. Once pictures of Covid-19 posters are received, LPA will notify Application Unit so application process may proceed.

No deficiencies cited at today’s inspection.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2021
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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