486804072-6-21-2024-21-AS-SMUU-D6FVG9-20240621162511

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486804072
Report Date: 06/21/2024
Date Signed: 06/21/2024 04:27:17 PM

Document Has Been Signed on 06/21/2024 04:27 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 III		FACILITY NUMBER:	486804072
ADMINISTRATOR:	ANTONIO, ANNABELLE		FACILITY TYPE:	740
ADDRESS:	147 COLUMBIA WAY		TELEPHONE:	5106854280
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94589
CAPACITY:	6	CENSUS: 7	DATE:	06/21/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Licensee, Alicia Poquiz and Caregiver Meriam Binalirao		TIME COMPLETED:	04:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	At approximately 9:00 AM, Licensing Program Analyst (LPA) Stefanie Mutialu made an unannounced annual required inspection of this licensed senior care facility. LPA was greeted by caregiver, Meriam Binalirao. Licensee, Alicia Poquiz arrived shortly after at approximately 10:45 AM. The facility is a single story home licensed for two (2) ambulatory residents, four (4) non-ambulatory residents and a hospice waiver capacity of three (3). The facility currently provides care for seven (7) residents. Facility is operating above the licensed capacity. Six out of seven residents were at home. Two out of seven was sleeping in her room, two out of seven were in the living room watching television, two of seven were outside smoking, and one of seven was away with his father. In addition, there are two (2) residents with a diagnosis of dementia At approximately 09:15 AM, LPA and Caregiver toured the building and grounds which was found to be clean. All notices that are required to be posted have been posted and are in a highly visible area. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins are stored in a locked cabinet in the facility garage but some toxins found unsecure.. Sharps and other kitchen supplies that could pose danger if available to residents were found secured in the kitchen drawer. There was a supply of cleaners, hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings. LPA advised Caregiver all hallways and non-private bathrooms are required to have night light Water temperature measured within regulation between 114 and 118 degrees F at three of three faucets accessible to residents. One out of one fire extinguisher was inspected and charged. Nine out Nine interconnected smoke detectors and two out of two carbon monoxide detectors were present, inspected and found to be in working order. There was enough lighting in all common areas and resident rooms. Continued on 809C

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR NAME: Stefanie Mutialu	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 III	FACILITY NUMBER: 486804072
	VISIT DATE: 06/21/2024

NARRATIVE

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Continued from 809

Medications located in designated cabinet were found to be secured. LPA conducted a spot check of medications and found medication administering pre-pouring error.

Per approved Fire Inspection Facility Sketch dated 07/22/2022, Licensee is using designated Resident Bedroom #2 as a Staff Room and designated Staff Bedroom as a Resident Bedroom. In addition, the two Extra bedrooms located next to the designated Staff Room is being used as Resident Rooms. Licensee to provide updated Facility Sketch to CCLD for new Fire Inspection Request.

At approximately 10:30 AM, LPA reviewed Seven of Seven resident records which were all found to be well organized. At approximately 11:39 AM, LPA reviewed two out of two staff records which were all found to be well organized. Medication records contained physician's orders for each resident.

Administrator Annabelle Antonio Administrator Certification 7028257740 is current and expires on 11/20/2024.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:
LIC500- Personnel Report
LIC9020 Register of Facility Clients/Residents
LIC610- Disaster Plan (to include non-local evacuation site)
Dementia Care Plan
Job Description/Personnel Policies
Evidence of Liability Insurance

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

This report was reviewed with Alicia Poquiz and Appeal rights were given.

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR NAME: Stefanie Mutialu	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/21/2024 04:27 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 III	FACILITY NUMBER: 486804072
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87204(a)

Limitations -Capacity and Ambulatory Status

(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in the licensee is operating the facility beyond the conditions and limitations specified on the license by caring for seven (7) residents which more than the licensed capacity to care for a maximum of six (6) residents in the facility, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/22/2024
	Plan of Correction
1 2 3 4	Two residents moved out during inspection. Licensee shall remove bed from the facility in the extra room that seventh resident was staying and submit photo proof of correction to CCLD by POC of 06/22/2024.

Type A

Section Cited

CCR

87705(f)(2)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above in which toxin and chemicals were found accessible to residents with dementia located within the facility, Clorox bathroom cleaner was found in Resident room #6 shared bathroom in a unlocked cabinet under the sink and cans of paint and chemicals was found in the backyard near the residents smoking area, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/22/2024
	Plan of Correction
1 2 3 4	Licensee removed or secured all toxins during inspection.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR NAME: Stefanie Mutialu	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/21/2024 04:27 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 III	FACILITY NUMBER: 486804072
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(h)(5)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in seven] out of seven residents medications was prepoured into a seven day multi-color vitamin case, medications were transferred between containers, and not stored in its orginal received container,which poses/posed a potential health and safety risk to persons in care.
	POC Due Date: 06/22/2024
	Plan of Correction
1 2 3 4	Licensee to provide plan of medication administration retraining to all caregivers to include time and date training will be completed and individual topics covered. Licensee to submit LIC9098 certifying that medication will not be prepoured and all medication will be administered according Tilte 22 Regulation. and Health & Safety Code

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR NAME: Stefanie Mutialu	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/21/2024 04:27 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 III	FACILITY NUMBER: 486804072
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(I)(1),(2)

(l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates (1) Licensees shall notify the licensing agency of their intention to lock exterior doors and/or perimeter fence gates. (2) The licensee shall ensure that the fire clearance includes approval of locked exterior doors or locked perimeter fence gates. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that LPA observed side gate chained up and locked with a padlock which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/22/2024
	Plan of Correction
1 2 3 4	Licensee removed chain and pad lock from side gate during inspection.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR NAME: Stefanie Mutialu	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2024

LIC809 (FAS) - (06/04)

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