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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200769
Report Date: 11/29/2021
Date Signed: 11/29/2021 09:48:29 AM

Document Has Been Signed on 11/29/2021 09:48 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 IIIFACILITY NUMBER:
079200769
ADMINISTRATOR:WEBSTER, PIAFACILITY TYPE:
735
ADDRESS:351 JOAN VISTA STREETTELEPHONE:
(510) 222-9212
CITY:EL SOBRANTESTATE: CAZIP CODE:
94803
CAPACITY: 4CENSUS: 3DATE:
11/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Pia Webster, AdministratorTIME COMPLETED:
10:00 AM
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On 11/29/2021 starting at 8:40 AM, Licensing Program Analyst (LPA) Catherine Lin arrived unannounced to conduct Infection Control Inspection. LPA met with staff Noah Wilkins and explained the purpose of the visit. (Administrator, Pia Webster later arrived at 9:00am.)

Upon entry, LPA’s temperature was checked by the staff, asked to sign-in, and requested to wash hands or use gloves. LPA toured facility including but not limited to front entrance, screening station, hand washing station, bedrooms, bathrooms, kitchen, common areas, and outdoor areas. There is one central entry point for universal screening for staff, residents, and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette and hand washing posters were observed. Facility staff were observed to be wearing proper PPE.

Facility has a sufficient 2-day perishable and one-week non-perishable food supply. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. Facility has Mitigation Plan, Emergency Disaster Plan, and maintains record of routine screening for residents, staff, and visitors.

No deficiency cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE: DATE: 11/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/29/2021
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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