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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200767
Report Date: 09/28/2021
Date Signed: 09/28/2021 11:27:56 AM

Document Has Been Signed on 09/28/2021 11:27 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, 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:
09/28/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Rufus Webster, CaregiverTIME COMPLETED:
11:35 AM
NARRATIVE
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On 09/28/2021 at 11:00AM, Licensing Program Analysts (LPAs) L. Hall and C. Fowler arrived unannounced to conduct a Case Management Inspection. LPAs met with Caregiver, Rufus Webster. LPAs spoke with Administrator, Pia Webster via telephone to approve Caregiver to sign document.

Analyst of the day received a phone call on 9/2/2021 from Administrator, Pia Webster stating that 6 clients will be relocated to a hotel due to remodeling of the facility floors. LPA was informed that CCLD was not notified prior to remodeling.

The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 . Failure to correct deficiency may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2021
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 09/28/2021 11:27 AM - It Cannot Be Edited


Created By: Laura Hall On 09/28/2021 at 11:18 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: 09/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/05/2021
Section Cited
CCR
80086(a)

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80086 Alterations to Existing Building or New Facilities
(a) Prior to construction or alterations, all licensees shall notify the licensing agency of the proposed change. This requirement was not met as evidence by:
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Administrator has agreed to review reporting requirements and submit signed written statement of understanding to CCLD by POC date.
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Based on interview, the licensee did not comply with the section cited above by not notifying CCLD of remodeling which poses a potential health and safety risk to persons 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:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2021


LIC809 (FAS) - (06/04)
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