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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486804193
Report Date: 10/09/2026
Date Signed: 10/09/2026 11:55:32 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/07/2026 and conducted by Evaluator Star Stevenson
COMPLAINT CONTROL NUMBER: 21-AS-20260807134652
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: 6DATE:
10/09/2026
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Caregiver Laurie Gonzales-Designation of Facility Responsibilty. TIME COMPLETED:
12:10 PM
ALLEGATION(S):
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Facility did not provide timely medical attention to resident in care
INVESTIGATION FINDINGS:
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On 10/09/2026 Licensing Program Analyst (LPA) Star Stevenson arrived unannounced to deliver findings of a complaint received by Community Care Licensing (CCL) on 08/07/2026. LPA met with Caregiver Laurie Gonzales who has Designation of Facility Responsibility (RP). RP called Licensee Alicia Poquiz by phone. LPA spoke briefly to Licensee by phone about the results of the investigation and Licensee advised that RP would sign today’s report.

The complaint alleges that Resident (R1) attempted to self-harm themselves on the night of 08/05/2026 and again on the morning of 08/06/2026 but the facility failed to seek timely medical treatment for R1.

LPA’s interview with R1 confirmed self-harm attempt on 8/5/2026 and 8/6/2026 and a record review of R1 documents at Ware Residential Care IV revealed that R1 was known to have Major Depression, history of “self abuse” and Suicidal Ideation (see page 5 of R1’s Physican Report dated 06/03/2026) before moving to Ward Residential Care Home IV.
Continued on LIC9099-C

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Star Stevenson
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 21-AS-20260807134652
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/09/2026
NARRATIVE
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Continued from LIC9099
An interview with the complainant revealed that an outside caregiver (W1) who was not employed by the facility, called a local hospital at 3:40 PM on 08/06/2026 to report the attempts at self-harm by R1 with R1 being admitted to an outside hospital by 5:40 PM that same day.

Interviews with staff members S1, S2, S3, S4 all agreed that it was W1 that reached out to a local hospital to inform them of R1’s attempt to harm themselves.
Both staff members, S2 and S3, report having removed a phone charging cord hanging off the shoulders of R1, but it was not clear if this represented two different occasions of removal or of poor recollection on the parts of S2 and S3.

S1 and Resident (R2) reported it was S2 that removed a phone cord off the shoulders of R1.

Review of documents provided by the facility reveal that R1’s Physician Report on page 5 of 9 indicates that R1 had a history of depression, suicidal ideation and self-abuse and “poor” overall mental health.

Additional review of R1’s Preplacement Appraisal, Appraisal/Needs and Service Plan and Resident Appraisal provided by S1, all indicate R1 had a history of depression; while a review of an Order Summary Report provided to the facility and dated 06/02/2026 (before latest self-harm incident) indicates R1 had “Major Depressive Disorder” with R1 on medication for “verbalization for sad thoughts, and hopelessness related to Major Depressive Disorder.”

Facility staff failed to seek timely medical after R1’s self-harm attempts resulting in W1 calling the acute hospital on behalf of R1 on the afternoon of 08/06/2026, therefore allegation that the facility did not seek timely medical attention for R1 is Substantiated and the preponderance of evidence standard has been met (see 9099-D page) for Type A citation for CCR 87466.
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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 RP Laurie Gonzales and Appeal rights were given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Star Stevenson
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20260807134652
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/12/2026
Section Cited
CCR
87466
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87456 Observation of the Resident: The Licensee shall ensure that residents are regularly observed for changes...and that appropriate assistance is provided...and brought to the attention of the Resident's Physician...This requirement was not met as evidenced by: Based on interviews, record
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Licensee to submit self-certification that in-service training will be conducted with all staff reviewing regulation 87466 (Observation of Resident. Self-certification of planned all staff training to be submitted by Plan of Correction (POC) due date 10/12/2026. Training to included the following: Date, Topic, Job Role
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review and observation, Licensee did not ensure that Resident 1 (R1) recieve timely medical care. R1 acted and expressed self harm ideation and the facility failed to notify R1's Physican right away.
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Staff Names, and Signatures. Training and supporting documents to be submitted to Community Care Licensing (CCL) for review and approval by second POC due date of 11/09/2026
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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: Bethany Moellers
LICENSING EVALUATOR NAME: Star Stevenson
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2026
LIC9099 (FAS) - (06/04)
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