486803937-8-5-2021-21-AS-DTOA-C5LS8G-20210805133907

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803937
Report Date: 08/05/2021
Date Signed: 08/05/2021 01:39:20 PM

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 I		FACILITY NUMBER:	486803937
ADMINISTRATOR:	POQUIZ, ALICIA		FACILITY TYPE:	740
ADDRESS:	110 WARD CT		TELEPHONE:	(707) 643-6331
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94589
CAPACITY:	6	CENSUS: 6	DATE:	08/05/2021
TYPE OF VISIT:	Post Licensing	UNANNOUNCED	TIME BEGAN:	11:25 AM
MET WITH:	Alicia Poquiz, Licensee		TIME COMPLETED:	01:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Tobola conducted an unannounced post-licensing inspection to this facility and was greeted by Licensee Alicia Poquiz. Facility currently has 6 residents in care one (1) of which admitted to a crisis center and returning today and some of which with a diagnosis of dementia. LPA toured the facility on 08/05/2021 with Licensee and facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on 6/9/2021. Facility smoke detectors and carbon monoxide detectors were connected, tested and found to be in working order. Hot water temperature measured between 109.7 and 110.1 degrees F in 2 out of 2 resident’s bathroom faucets within Title 22 acceptable regulation of 105 to 120 degrees F. Toxins are stored in a locked cabinet in the kitchen and laundry room. Dangerous items were stored inaccessible to residents with dementia. There was a supply of cleaners, hygiene products and paper products available for residents. The bathroom designated for residents at the facility were supplied with individual paper towels; hand soap dispenser was available. All 6 residents' bedrooms have lighting & appropriate furnishings. LPA conducted a file review for both staff and residents and found all files to be in order. Medications are centrally stored in a locked cabinet in the facility kitchen and hallway. LPA observed multiple unsecured prescription medication in the refrigerator (photo taken). Licensee immediately moved medications in a lockbox which will be kept in the refrigerator. Facility has PPE supply stored in the facility garage. In addition, LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Disaster Drills will be conducted bi-annually with the first drill to be completed next month. Appeal Rights Given.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 I	FACILITY NUMBER: 486803937
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/05/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(2)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above in 7 of 7 prescription medications accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/06/2021
	Plan of Correction
1 2 3 4	Licensee failed to ensure medications were stored inaccessible to residents in care with a diagnosis of dementia. Licensee immediately removed medications and placed them in a secured lockbox which will continue to be stored in the refrigerator. LIcensee agrees to review regualtion 87705 with all staff. POC cleared at the time of visit.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2021

LIC809 (FAS) - (06/04)

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