<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804193
Report Date: 10/23/2025
Date Signed: 10/23/2025 03:23:36 PM

Document Has Been Signed on 10/23/2025 03:23 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 IVFACILITY NUMBER:
486804193
ADMINISTRATOR/
DIRECTOR:		ANTONIO, ANNABELLEFACILITY TYPE:
740
ADDRESS:451 NEW BEDFORD DRIVETELEPHONE:
(510) 685-4280
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 6CENSUS: DATE:
10/23/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:35 PM
MET WITH:Licensee Alicia PoquizTIME VISIT/
INSPECTION COMPLETED:
03:35 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 1:35 PM Licensing Program Analyst (LPA) Star Stevenson arrived unannounced to BEGIN a required 1-year inspection of this licensed senior care facility. LPA was greeted by one live-in caregiver and another caregiver who are both associated to the facility via Guardian. The live-in caregiver called the Licensee, Alicia Poquiz who arrived at approximately 2:15 PM. The Facility has fire clearance for six (6) residents and approved for 5 non-ambulatory residents and one (1) bedridden resident in room #5. Room #1 is approved for two (2) ambulatory residents only. Room five (5) and room six (6) ADU (back yard shed) are for staff use only.
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 need a deep cleaning, licensee was advised to remove trash and broken appliances in the backyard and to be mindful to reduce trip hazards at all times. (Technical violation issued). In addition a number of light bulbs in the living room were missing and licensee was advised to replace the bulbs with residents with potential vision issues. Facility was 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. Licensee and I observed leaking fluids of possible juice and meat in a garage refrigerator and licensee advised to perform a deep cleaning and inspect food for quality (type B citation issued)

Outside ADU was noted to be locked and contained only staff items inside, a separate large shed contained hardware and supplies.

Continued on LIC809C
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/23/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 11
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 11
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 IV
FACILITY NUMBER: 486804193
VISIT DATE: 10/23/2025
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
26
27
28
29
30
31
32
Continue from LIC809

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. A locking cleaning supply closet was noted to be open with staff present and licensee was advised to ensure that cleaning supplies were secured and locked at all times. (technical violation issued) There was a supply of hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings.

Water temperature measured between 105 and 120F as required by regulation. Smoke detectors and carbon monoxide detectors were present, inspected and found to be in working order. Fire extinguisher was charged with proof of service in June of 2024. Facility has a central fire alarm system that was tested by outside party on 11/17/2024

LPA request copies of Deed and updated Liability insurance,LIC500 and LIC9020 and LIC308 (Designation of facility responsibility; if changes) to be submitted to CCL by 11/23/2025

**LPA will return at a future un-announced date to complete inspection including facility files and medication administration review.

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 Licensee, Alicia Poquiz and Appeal rights were given.
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2025
LIC809 (FAS) - (06/04)
Page: 3 of 11
Document Has Been Signed on 10/23/2025 03:23 PM - It Cannot Be Edited


Created By: Star Stevenson On 10/23/2025 at 03:02 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 IV
FACILITY NUMBER: 486804193

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(9)
General Food Service Requirements
(b) The following food service requirements shall apply: (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview the licensee did not comply with the section cited above in one (1) out of three (3) refridgerators which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/04/2025
Plan of Correction
1
2
3
4
Licensee to deep clean garage refridgerator and submit to community care licensing picture of the refridgerator completely cleaned out of food and clean and then a picture of the refridgerator re-stocked and clean.
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.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Star Stevenson
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2025


LIC809 (FAS) - (06/04)
Page: 4 of 11