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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200767
Report Date: 03/14/2022
Date Signed: 03/14/2022 02:37:57 PM

Document Has Been Signed on 03/14/2022 02:37 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:WEBSTER FAMILY CARE HOME IFACILITY NUMBER:
079200767
ADMINISTRATOR:WEBSTER, PIAFACILITY TYPE:
735
ADDRESS:1810 MINER AVENUETELEPHONE:
(510) 812-7107
CITY:SAN PABLOSTATE: CAZIP CODE:
94806
CAPACITY: 6CENSUS: 6DATE:
03/14/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Pia Webster, AdministratorTIME COMPLETED:
02:45 PM
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On 3/14/2022 at 2:00PM, Licensing Program Analysts(LPAs)C. Fowler and L. Hall conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 3/8/2022. LPAs met with Pia Webster, Administrator ,and explained the purpose of the visit.

Incident report dated 3/8/2022 revealed Client 1 (C1) and Client 2 ( C2) was involved in an physical altercation.

During visit LPAs interviewed staff. C1 and C2 has shared a room for approximately 1 year. During interviews staff explained to the LPAs the behaviors of C2. Staff explained that C2 have been given behavioral tools to decompress when needed. Staff also indicated that there has not been any other incident of this type between C1 and C2. LPAs obtained via email the Behavioral Assessment and Plan.

No deficiencies cited during visit.


Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2022
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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