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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803937
Report Date: 08/19/2022
Date Signed: 08/19/2022 04:01:42 PM


Document Has Been Signed on 08/19/2022 04:01 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: 5DATE:
08/19/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Licensee, Alicia PoquizTIME COMPLETED:
04:10 PM
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On 8/19/2022 Licensing Program Analyst (LPA) Tobola conducted an unannounced Case Management visit for the purpose of following up on an incident report and coinciding report of suspected abuse (SOC341) in which resident (R1) was reported to have physically injured staff (S1).

LPA conducted interviews with Licensee, staff, clients, reviewed records and made observations. On the date of the incident, 8/3/2022, LPA found that Licensee contacted Vallejo Police Department and that S1 originally decided to file charges against R1 leading to R1 being arrested. LPA was informed that a court hearing will be scheduled for Licensee and S1 to attend. However, S1 has decided to not file charges with the decision to no longer accept R1 back to the facility.

All staff including S1 and all residents were observed to be comfortable and in a safe condition.

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: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2022
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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