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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803937
Report Date: 05/06/2022
Date Signed: 05/06/2022 12:17:02 PM


Document Has Been Signed on 05/06/2022 12:17 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 IFACILITY NUMBER:
486803937
ADMINISTRATOR:POQUIZ, ALICIAFACILITY TYPE:
740
ADDRESS:110 WARD CTTELEPHONE:
(707) 643-6331
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY:6CENSUS: 6DATE:
05/06/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Gracia Samonte, Lead Staff TIME COMPLETED:
12:25 PM
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On 5/6/2022 LPA Tobola arrived unannounced for the purpose of following up on a facility self-reported incident in which resident R1 AWOL during an outing with R1's Case Manager. LPA was greeted by Lead Staff, Gracia Samonte. LPA contacted Licensee, Alicia Poquiz who was unable to meet at the time of visit but spoke with LPA by phone and provided additional information.

On 4/29/2022 R1 was reported to have attended an program at the Caminar Wellness Center with a second resident R2 . Both R1 and R2 were transported by their Solano County Case Manager. Upon the end of the program the Solano County Case Manager was informed that R1 had a verbal altercation with another program participant and left the Caminar Wellness Center without notifying Wellness Center staff. Solano County Case Manager was unable to locate R1 and reported the AWOL to the Licensee, Alicia Poquiz and facility Caregiver Staff. R1 was on an outing with their father at the time of visit today.

Acting Administrator, Victoria Lim had contacted Vallejo Police Department to report R1 as a missing person. R1's father was also notified by facility. LPA spoke with Lead Staff and was informed that R1's father had visited several hospitals in Solano County and located R1 at Sutter Solano on 4/30/2022. R1 was discharged and returned to the facility on 4/30/2022.

Licensee has conducted meetings with R1's and R2's Case Manager and are currently postponing attendance to the Caminar Wellness Center to find more appropriate placement for resident supervision.

Report was reviewed with Lead Staff and Licensee.

No deficiencies cited during today's visit.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:
DATE: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2022
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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