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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200769
Report Date: 06/09/2023
Date Signed: 06/09/2023 12:21:22 PM

Document Has Been Signed on 06/09/2023 12:21 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:
06/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Pia Webster, AdministratorTIME COMPLETED:
12:30 PM
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On 06/09/23 around 10:00 AM, Licensing Program Analyst (LPA) L. Holmes arrived announced to conduct a required Annual Inspection. LPA was greeted by Pia Webster, Administrator (ADM) upon entry and explained the purpose of the visit. The Standard Certificate (#6012644735) expires 02/25/24.

The facility has an Infection Control Plan (ICP) on file. All clients are at their respective programs. LPA reviewed the resident files, staff files and Emergency Disaster Plan (EDP). LPA observed a visitor sign-in log and a COVID-19 screening station. LPA and ADM toured the facility, including but not limited to bedrooms, bathroom, kitchen, garage, common area, front yard and backyard. The facility consists of four (4) total bedrooms. All indoor passageways were free of obstruction. There aren't any bodies of water. A comfortable temperature for the clients was maintained; the windows and front door was ajar to circulate fresh air. The water temperature measured at 114.8 for the comfort and safety of all the clients. The bathroom was safe, sanitary and in operating condition. Hand washing posters, paper towels, and soap observed at all hand washing stations. Linen and hygiene supplies were available for all clients. PPE and paper goods remain sufficient. First Aid kit, cleaning supplies, sharps, and medications are safely stored and locked in the garage. There is a minimum supply of 2-day perishables and 7-days of non-perishable foods.

continued on LIC809C...
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 06/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/09/2023
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: 06/09/2023
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...continued from LIC809

Smoke detectors/carbon monoxide were in operating condition during visit. Fire extinguisher last serviced on 03/29/23, first aid kit observed complete, fire drill and emergency disaster drill was last conducted on 05/16/23.

Five (5) staff files reviewed all had criminal record clearance, first-aid, and CPR. Four (4) client files reviewed were complete.

The following forms are to be updated:
-LIC500 Personnel Report (Reviewed)
-LIC308 Designation of Administrative Responsibility (Reviewed)
-LIC610D Emergency Disaster Plan (Reviewed)
-Administrator Standard Certificate (Reviewed)

No deficiencies cited, exit interview conducted and a copy of this report provided to Pia Webster, Administrator
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2023
LIC809 (FAS) - (06/04)
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