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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200769
Report Date: 05/28/2024
Date Signed: 05/28/2024 05:04:19 PM

Document Has Been Signed on 05/28/2024 05:04 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/
DIRECTOR:		WEBSTER, PIAFACILITY TYPE:
735
ADDRESS:351 JOAN VISTA STREETTELEPHONE:
(510) 222-9212
CITY:EL SOBRANTESTATE: CAZIP CODE:
94803
CAPACITY: 4CENSUS: 4DATE:
05/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:45 PM
MET WITH:Pia Webster, AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
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On 05/28/24 around 02:45 PM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct a required Annual Inspection. LPA was greeted by one (1) Care Staff who telephoned Pia Webster, Administrator (ADM) who arrived about ten (10) minutes later. LPA explained the purpose of the visit to ADM. The Standard Certificate (#6012644735) expired 02/25/24 and is waiting completion of the renewal.

Upon arrival three (3) of the clients were lounging in the facility and one (1) was at their respective program. LPA reviewed the resident files, staff files and Emergency Disaster Plan (EDP). LPA observed COVID-19 signs and protocol. 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 was not any bodies of water. A comfortable temperature for the clients was maintained; the doors were ajar to circulate fresh air. The water temperature measured at 110.8 Fahrenheit (F) for the comfort and safety of all the clients. The bathroom was safe, sanitary and in operating condition. Hand soap, 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 was 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: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/28/2024
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: 05/28/2024
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...continued from LIC809

Smoke detectors/carbon monoxide were in operating condition during visit. Fire extinguisher last serviced on 02/28/24, and emergency disaster drill was last conducted on 05/08/24.

Three (3) staff files reviewed 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, ADM.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024
LIC809 (FAS) - (06/04)
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