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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804193
Report Date: 12/23/2024
Date Signed: 12/25/2024 11:15:04 AM

Document Has Been Signed on 12/25/2024 11:15 AM - 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/
DIRECTOR:
ANTONIO, ANNABELLEFACILITY TYPE:
740
ADDRESS:451 NEW BEDFORD DRIVETELEPHONE:
(510) 685-4280
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 6CENSUS: 6DATE:
12/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:34 PM
MET WITH:Alicia PoquizTIME VISIT/
INSPECTION COMPLETED:
04:50 PM
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Licensing Program Analyst (LPA) Araceli Canela made an unannounced annual required 1 year inspection of this licensed senior care facility. LPA was greeted by two caregivers and Licensee, Alicia Poquiz arrived shortly after. The facility is a two story home and the second level of the home is not used by residents and there is a gate at the bottom of the stairs to prevent residents going up the stairs. The facility currently provides care for six (6) residents.

LPA toured the building and grounds which was found to be clean, at a comfortable temperature, with all exits free from obstruction. All required postings were observed. 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 cabinets and Sharps and other kitchen supplies that could pose danger were found secured in the kitchen cabinet. There was a supply of hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings.

Water temperature measured at 107 degrees and within the required regulation. One out of one fire extinguisher was inspected and charged. Smoke detectors and carbon monoxide detectors were present, inspected and found to be in working order. Fire extinguisher was charged with proof of service 1/17/2024.

Resident files were reviewed (6) and were all found to be complete and organized. Staff files were reviewed and have current health screening, fingerprint clearance, proof of training. Medications are locked in cabinet in the living room.


Continued on LIC809C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/23/2024
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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: WARD RESIDENTIAL CARE HOME IV
FACILITY NUMBER: 486804193
VISIT DATE: 12/23/2024
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Licensee/Administrator to submit the current following documents by 1/15/2025:

· LIC 308 Designation of Facility Responsibility
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan
· LIC 9020 Register of Facility Residents
Infection Control Plan of Operation (If changes)
Copy of Liability Insurance

No citations issued during todays visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024
LIC809 (FAS) - (06/04)
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