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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200769
Report Date: 05/25/2022
Date Signed: 05/25/2022 01:04:11 PM

Document Has Been Signed on 05/25/2022 01:04 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 IIIFACILITY NUMBER:
079200769
ADMINISTRATOR:WEBSTER, PIAFACILITY TYPE:
735
ADDRESS:351 JOAN VISTA STREETTELEPHONE:
(510) 222-9212
CITY:EL SOBRANTESTATE: CAZIP CODE:
94803
CAPACITY: 4CENSUS: 4DATE:
05/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Fredia Smith, Care StaffTIME COMPLETED:
01:20 PM
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On 05/25/2022 at 11:40 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct an Infection Control Inspection. LPA was greeted upon entry by one client and one Care Staff, Fredia Smith; LPA explained the purpose of the visit. The Administrator, Pia Webster (ADM) was telephoned by the care staff and will try to be present for the inspection. Pia Webster arrived about 12:00 PM.

Facility has a COVID-19 mitigation plan on file. LPA obtained a staff and resident roster. LPA observed a screening station that contained a thermometer, hand sanitizer, gloves, COVID-19 signage, and a sign-in log along with an isolation cart stocked with PPE. LPA toured the facility including, but not limited to common areas, bathrooms, bedrooms, kitchen, garage and backyard. LPA observed masks, cough etiquette, social distancing and hand washing signs posted throughout. Hand washing signs, covered garbage cans, soap and paper towels are in shared bathrooms and kitchen. There was a sufficient supply of 2-day perishables and 7-day supply of non-perishable foods. There is a surplus of PPE stored in the garage and centrally located inside the facility that is accessible to all care staff. Hot water temperature in the shared residents' bathroom was measured at 108 degrees Fahrenheit (F) and the facility's temperature was 82 degrees (F). Fire extinguisher was observed full and last inspected on 03/23/2022. Smoke/Carbon Monoxide detectors were observed operational, fire drills performed regularly, staff are fit tested and first aid kit complete.

The following forms are updated:
-LIC500 Personnel Report (Reviewed)
-LIC308 Designation of Administrative Responsibility (Reviewed)
-LIC610E Emergency Disaster Plan (Reviewed)
-An updated copy of Administrator Certificate(s) (Reviewed)

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 05/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/25/2022
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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