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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200769
Report Date: 08/12/2022
Date Signed: 08/12/2022 01:50:02 PM

Document Has Been Signed on 08/12/2022 01:50 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:
08/12/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Administrator, Pia Webster TIME COMPLETED:
02:00 PM
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On 08/12/22 at 12:45 PM, LPA L. Holmes conducted an unannounced case management visit. No one was at the facility. LPA telephone Administrator (ADM) Pia Webster, she is in Berkeley and can return. LPA explained the purpose of the visit was to discuss the self reported incident received by CCL on 08/06/22 regarding a medication error. ADM arrived at 01:20 PM.

On 08/09/2022 at about 8:00 AM, Administrator, Pia Webster (ADM) received a telephone call from the Direct Support Professional (DSP)/Staff #1 (S1) stating that he/she had given Consumer/Client #1 (C1) the meds that belonged to Consumer/Client #2 (C2). S1 stated that he/she was rushing around and answered the front door. When S1 returned to administering medication to C1, he/she realized after C1 took the medication that was for C2. S1 had administered the wrong medication to C1. C1 received the following medications: (Antihypertensive) Benazepril/HCTZ 10-12.5mg x1, (Antidepressant) Citalopram 20mg (1/2 tab), and (Antidepressant) Citalopram 10mg (1/2 tab). C1’s primary medical doctor, psychiatrist and Nurse Kaman were contacted, no new orders were received and C1’s doctor is to follow-up. C1 was monitored throughout the day and there was no change in conditions. R2’s replacement medication was ordered from the Pharmacy the same day and to arrive on 08/12/22. The MAR’s for C1 and C2 are accurate, completed and up to date for 08/2022.

...continued on LIC 809-C

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/11/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 III
FACILITY NUMBER: 079200769
VISIT DATE: 08/12/2022
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continued from LIC 809...

To ensure this doesn’t happen again, Staff received re-education/training on medication administration utilizing the Direct Support Professional (DSP) medication training manual; training started on 08/09/2022 for S1. ADM reviewed medication procedures with S1 to include that all medications be administered from the office at the medication cabinet, medications shall not leave the office (the only exception is if a Consumer/Client is ill and confined to his/her room), and there are to be no interruptions/distractions or talking while administering medications. Medication shall be administered to one Consumer/Client at a time and all medication must be witnessed by the Staff as the Consumer/Client self administers his/her own medication.

No deficiencies cited during this visit. Exit interview conducted and copy of this report provided to Administrator Pia Webster.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022
LIC809 (FAS) - (06/04)
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