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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803937
Report Date: 03/20/2025
Date Signed: 03/20/2025 03:13:43 PM

Document Has Been Signed on 03/20/2025 03:13 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/
DIRECTOR:		POQUIZ, ALICIAFACILITY TYPE:
740
ADDRESS:110 WARD CTTELEPHONE:
(707) 643-6331
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 6CENSUS: 6DATE:
03/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Alicia Poquiz, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:25 PM
NARRATIVE
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At approximately 9:00 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a required 1 Year visit and was greeted by Caregiver Rowena Vengua. Administrator Alicia Poquiz arrived at 9:30 AM. Ward Residential Care Home I is Licensed as a Residential Care Facility for the Elderly (RCFE). The facility is a single story ranch house. The facility has an approved fire clearance for six (6) Residents. Four (4) residents may be non-ambulatory. The facility has a Hospice Waiver for three (3) residents. Upon arrival, LPA was informed that there were six (6) residents in care. At approximately 9:35 AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation.

At approximately 9:40 AM, LPA toured the facility with Administrator Poquiz. All exits were clear and unobstructed. The two (2) fire extinguishers were last serviced and tagged on 6/17/2024. The facility was sufficiently lighted. LPA inspected three (3) resident bedrooms and found all to have sufficient lighting and furnishings as required per Title 22 Regulations. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Toxins were observed to be stored inaccessible to residents. Facility has an infection control plan as required. The facility has a required emergency disaster plan. The facility is conducting fire and emergency drills quarterly. The last disaster drill was conducted on 1/20/2025. The facility does have emergency food and supplies to meet the "72 hour shelter in place" requirements. Hot water temperatures for all sinks in facility were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. Facility smoke detectors and carbon monoxide detectors were tested and observed to be operational.

Continued on 809-C
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2025
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 I
FACILITY NUMBER: 486803937
VISIT DATE: 03/20/2025
NARRATIVE
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...Continued from 809

At approximately 10:25 AM, LPA reviewed six (6) resident files. LPA observed that Resident one (R1) did not have a Consent for Emergency Medical Treatment form or an LIC 613 Personal Rights form in their File. LPA observed that Resident two (R2) had a medical assessment dated (3) months after admission to the facility. R2's file was also observed to have the pre-placement assessment written after their date of admission. R2 was further observed to have their LIC 613 Personal Rights form from a previous facility to which they were admitted. These deficiencies will be cited. The remaining four (4) resident files were observed to have all required documentation. LPA reviewed three (3) staff files. All staff files were found with all required documentation including First Aid and CPR certification and proper training documentation. LPA spot checked Medication for three (3) residents. LPA observed all medications to be centrally stored, secure and with proper documentation. The facility does not handle resident’s monies for personal and incidental items.

Alicia Poquiz’s Administrator Certification 7001402740 is current with an expiration date of 11/20/2025.

LPA requested the following documents be submitted to Community Care Licensing by 4/20/2025:



LIC 500 Personnel Report
LIC 308 Designation of Responsibility
LIC 610E Emergency Disaster Plan
Proof 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, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC-809Ds, Plan of Corrections, 811 Confidential Names and Appeal Rights discussed and provided to Administrator Poquiz. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 03/20/2025 03:13 PM - It Cannot Be Edited


Created By: Robert Frank On 03/20/2025 at 02:33 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: WARD RESIDENTIAL CARE HOME I
FACILITY NUMBER: 486803937

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87456(a)(2)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in that a pre-admission appraisal was not completed prior to admission for R2 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2025
Plan of Correction
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Licensee/Administrator will self certify that they understand that a preadmission appraisal must be completed prior to the resident being admitted to the facility on or before the POC Due Date of 4/18/2025
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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
LICENSING EVALUATOR NAME:Robert Frank
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2025


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 03/20/2025 03:13 PM - It Cannot Be Edited


Created By: Robert Frank On 03/20/2025 at 02:43 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: WARD RESIDENTIAL CARE HOME I
FACILITY NUMBER: 486803937

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(b)(1)(A)
87468 Personal Rights
(b) At the time the admission agreement is signed, a resident and the resident's representative shall be personally advised of and given a copy of:
(1)The personal rights of residents specified in Sections 87468.1, Personal Rights of Residents in All Facilities or and 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities, as applicable to the facility.
(A)The licensee shall have each resident and the resident's representative sign a copy of these rights, and the signed copy shall be included in the resident's record.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in that R1 did not have an LIC 613 Personal Rights document in their file. R2's LIC 613 Personal Rights form was from a different facility to which they were previously admitted which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/10/2025
Plan of Correction
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Licensee/Administrator will submit to Community Care Licensing signed LIC 613 Personal Rights documents for R1 and R2 on or before the POC due date of 4/10/2025.
Type B
Section Cited
CCR
87458(a)
87458 Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in that R2's Medical Assessment was not completed prior to their admission to the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/22/2025
Plan of Correction
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Licensee/Administrator will submit to Community Care Licensing a current medical assessment for R2 on or before the POC Due Date of 5/22/2025.
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
LICENSING EVALUATOR NAME:Robert Frank
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2025


LIC809 (FAS) - (06/04)
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