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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804072
Report Date: 10/13/2022
Date Signed: 10/13/2022 02:36:11 PM


Document Has Been Signed on 10/13/2022 02:36 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 IIIFACILITY NUMBER:
486804072
ADMINISTRATOR:ANTONIO, ANNABELLEFACILITY TYPE:
740
ADDRESS:147 COLUMBIA WAYTELEPHONE:
(510) 685-4280
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY:6CENSUS: 6DATE:
10/13/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
01:31 PM
MET WITH:Alicia Poquiz, LicenseeTIME COMPLETED:
02:45 PM
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On 10/13/2022, Licensing Program Analyst (LPA) Tobola conducted an unannounced POST licensing inspection of this licensed residential care facility. LPA was initially greeted by caregiver. Licensee was contacted and arrived during the inspection. LPA toured the building and grounds which were found to be clean and in good repair. There are currently 6 residents in care all of which were present. All walkways and exits were observed to be unobstructed.

The amount of fresh and nonperishable foods were observed and found to be within regulation. Toxins are stored in garage and secured kitchen cabinets and are therefore inaccessible to residents in care. Medications are centrally stored in a locked cabinet located in facility hallway. Fire extinguisher inspected and found to be newly purchased within the year. Carbon monoxide and smoke detectors were observed throughout the facility, tested and in working order. There was an ample supply of cleaners, hygiene products and paper products available for residents. Bathrooms were equipped with necessary grab bars and non-slip floors/mats. All bedrooms have lighting & appropriate furnishings. Exit alarms on exit doors were working properly.

LPA reviewed 2 staff records. 2 out of 2 staff have current CPR and First Aid training on file.

At primary entrance LPA observed temperature log and visitor sign in sheet. LPA observed COVID postings and hand sanitizer throughout facility.

No deficiencies cited during this inspection.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2022
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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