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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804072
Report Date: 09/29/2023
Date Signed: 09/29/2023 01:19:12 PM

Document Has Been Signed on 09/29/2023 01:19 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:
09/29/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Licensee, Alicia Poquiz
Caregiver, Meriam Binolirao		TIME COMPLETED:
01:30 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 Case Management-Annual Continuation. LPA was greeted at the door by Caregiver, Meriam Binolirao, and was granted access into the facility.

During the Case Management-Annual Continuation, Emergency Disaster Plan was reviewed during this inspection. Infection Control Plan needs to be updated (See LIC 9102-Technical Violation). LPA educated the Licensee on the importance of having an updated an Infection Control Plan and to provide updates yearly. Staff and three clients were interviewed and the remainder of the clients were not available for an interview. LPA requested the following documents to be sent:

LIC 500-Personnel Report
Updated Infection Control Plan
Updated Emergency Disaster Plan
LIC 308-Designation of Responsibility
LIC 400- Affidavit regarding Client Cash Resources
Liability insurance
Control of Property
Resident Roster
Staff Roster

No deficiencies were cited during today's Case Management-Annual Continuation. Exit interview was conducted and a copy of this report was given to the Licensee.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2023
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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