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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200767
Report Date: 08/17/2021
Date Signed: 08/17/2021 12:16:18 PM

Document Has Been Signed on 08/17/2021 12:16 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: 5DATE:
08/17/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:43 AM
MET WITH:Pia Webster & Stan WebsterTIME COMPLETED:
12:30 PM
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On 8/17/2021, Licensing Program Analyst (LPA) L. Ibo conducted a Case Management visit with S1 in relation to the special incident report received on 7/28/2021, S3 mistakenly given R2's medication to R1.

R1’s physician was notified, facility staffs monitored R1's status for 24 hrs. after the incident. Facility Administrator conducted medication training with S3 on 7/29/2021. S1 requested medication replacement for R2. R1 did not show any adverse reaction from the medication that was given by S3.

LPA requested for the following documents but not limited to, Medication Administration record for R1 & R2, residents’ roster.

Deficiencies are cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections by plan of correction due dates, and any repeat violations within 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2021
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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Document Has Been Signed on 08/17/2021 12:16 PM - It Cannot Be Edited


Created By: Leslie Ibo On 08/17/2021 at 11:30 AM
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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: WEBSTER FAMILY CARE HOME I
FACILITY NUMBER: 079200767

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/03/2021
Section Cited
CCR
80075(b)(5)(B)

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80075 Health Related Services (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (B) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
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Adminsitrator will re-train all staffs for medication management, proof of document training will need to send to LPA L.Ibo on or before the POC date.
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Based on interview and records review: S3 gave the R2's medication to R1, this poses a potential threat to the health and safety of clients in care.
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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:Harpreet Humpal
LICENSING EVALUATOR NAME:Leslie Ibo
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2021


LIC809 (FAS) - (06/04)
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