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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803937
Report Date: 03/27/2024
Date Signed: 03/27/2024 02:44:54 PM


Document Has Been Signed on 03/27/2024 02:44 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 IFACILITY NUMBER:
486803937
ADMINISTRATOR:POQUIZ, ALICIAFACILITY TYPE:
740
ADDRESS:110 WARD CTTELEPHONE:
(707) 643-6331
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY:6CENSUS: 6DATE:
03/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Alicia PoquizTIME COMPLETED:
02:55 PM
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LPA Hiratsuka conducted this unannounced annual visit.

This facility has a fire clearance for four non-ambulatory and two ambulatory for a total of six residents. There are three shared resident rooms and two staff rooms. There There is one full private bathroom in room #4. The only people who are allowed to use the private bathroom in Room #4 are the residents who live in that room. There is one full common bathroom. The backyard has a locked shed.

The following topics were discussed:
-last year Licensee/Administrator Alicia Poquiz submitted a request for an increase in capacity. She submitted a facility sketch with that request that was converting a staff room to a resident room. The request for the increase was denied and Licensee stated she is not going to pursue the increase in capacity. Today, Licensee stated she is going to ensure the staff room remains a staff room.
-there is proof the staff have training and the hours required. Discussed today were different ways to log the amount of training hours and topics to make it easier to track
-administrator's certificate. Administrator stated she submitted the renewal paperwork for the certificate and is still waiting for the renewal.

The following shall be updated and submitted to Community Care Licensing Division by April 16, 2024:
-LIC 308 designation of administrative responsibility
-current liability insurance
-LIC 500 facility personnel or staff schedule

No deficiencies cited.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2024
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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