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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804193
Report Date: 12/01/2023
Date Signed: 12/01/2023 03:41:59 PM


Document Has Been Signed on 12/01/2023 03:41 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 IVFACILITY NUMBER:
486804193
ADMINISTRATOR:ANTONIO, ANNABELLEFACILITY TYPE:
740
ADDRESS:451 NEW BEDFORD DRIVETELEPHONE:
(510) 685-4280
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: 0DATE:
12/01/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:11 PM
MET WITH:Alicia PoquizTIME COMPLETED:
03:12 PM
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Licensing Program Analyst (LPA) Araceli Canela conducted a pre-licensing inspection and was greeted by Licensee, Alicia Poquiz and Administrator, Annabelle Antonio. This pre-licensing inspection is being conducted as an initial facility application. Fire Clearance has been approved on 10/19/2023 for 4 non-ambulatory, of which 1 can be bedridden, and 2 Ambulatory residents, for a total capacity of 6. There are currently 0 residents in care.

LPA conducted a tour and inspection of the indoor and outdoor portions of the facility. The home is a two story home and the second floor is off limits and not used by residents, stairs are gated and prevent access to the second floor. The down stairs . Fire extinguisher was charged and current. Smoke detectors and carbon monoxide detectors were present and all functional. Exits were observed to be unobstructed. Hot water measured 115.0 degrees in faucets used by residents which falls within regulation between 105 & 120 degrees F. There was an ample supply of linens, dishes and cooking supplies. There was a sufficient hygiene products available for residents. LPA observed adequate food supply per facility capacity. Facility was found to be a comfortable temperature of 70 degrees F. Toxins were observed to be secured and locked under kitchen sink. In addition, all knives and other sharp items were found to be in a locked location in the kitchen.
Medications will be centrally stored in a locked cabinet in living room with medication records and files. Facility also has blank templates for incoming resident and staff records, all contained in a secured location.
Required postings such as Rights to resident councils, client's rights and Complaint Poster are posted at the main entrance of the facility.

Component III orientation was conducted with the Licensee Applicant.
The pre-licensing evaluation has been completed and there are no corrections needed.
This report was reviewed with applicant and an electronic copy was provided. Signatures on file.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 12/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/01/2023
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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