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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804072
Report Date: 08/30/2023
Date Signed: 08/30/2023 02:18:53 PM


Document Has Been Signed on 08/30/2023 02:18 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:
08/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Caregiver, Meriam Binolirao
Licensee, Alicia Poquiz
Administrator, Annabelle Antonio		TIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Ward Residential Care Home III for the purpose of conducting a Required 1 year inspection. LPA was greeted at the door by, Caregiver, Meriam Binolirao, and was granted access into the facility. Licensee arrived 30 minutes later.

LPA and Caregiver toured the facility. LPA observed the facility to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged in May 2023 at the time of the inspection. All smoke detectors and carbon monoxide detectors sound directly to the fire station. First Aid kit was inspected and found to be appropriate during the inspection. Water temperature in a sample of 2 of 2 residents bathroom measured at 117 degrees and is within acceptable range of 105 to 120 degrees F. There was sufficient perishable and non-perishable foods located in the kitchen. Knives and other hazardous items were locked and inaccessible to residents in care. There are special provisions made for individuals with special dietary needs. Food and Activity menu was presently available for viewing during the inspection. Cleaning products and other toxins were locked and inaccessible to residents in care. There was a supply of Linens, cleaners, hygiene products and paper products available for residents in care during the. All bathrooms designated for residents in the common areas at the facility were supplied with individual paper towels and hand soap. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. A tour of residents bedrooms were conducted, and bedrooms inspected have lighting and appropriate furnishing. Resident files were reviewed and were found to be appropriate during the inspection. Staff files were reviewed. LPA observed that 1 out of 2 staff files did not have the required training hours for the year of 2023 (See LIC 9102-Technical Advisory). LPA educated the Licensee on the importance of ensuring that ALL staff have the required annual training as outlined in Title 22 Regulations. Emergency Disaster Plan, Infection Control Plan, Staff and Resident interviews will be conducted at a later date and time. No deficiencies were cited during today's Required 1 year inspection. Exit interview was conducted and a copy of this report was emailed to the Licensee due to printer issues.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2023
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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