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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201113
Report Date: 10/11/2021
Date Signed: 10/11/2021 11:37:41 AM

Document Has Been Signed on 10/11/2021 11:37 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 IIFACILITY NUMBER:
079201113
ADMINISTRATOR:STAN WEBSTERFACILITY TYPE:
735
ADDRESS:2667 SHAMROCK DRIVETELEPHONE:
(510) 233-7247
CITY:SAN PABLOSTATE: CAZIP CODE:
94806
CAPACITY: 3CENSUS: 0DATE:
10/11/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Stan Webster, AdministratorTIME COMPLETED:
10:50 AM
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On 10/11/2021 at 09:30am Licensing Program Analysts (LPAs) C. Fowler and L. Hall conducted an announced pre-licensing inspection and met with Pia Webster, Licensee.

LPAs toured the clients bedrooms, bathrooms, common living areas, kitchen, garage and backyard. There are three (3) bedrooms and two (2) bathrooms. There is sufficient lighting around the facility. Clients' rooms are equipped with the proper furniture, bedding and lighting. Passageways and hallways are free of obstruction. Hot water temperature is measured at 105.0 degrees Fahrenheit. LPAs observed locked cabinets that will store medications, toxins and sharps. Required posters are posted on the wall. Thermometer in hallway showed temperature as 68 degrees F. Emergency disaster plan dated 08/17/2021. Fire extinguisher was last serviced on 03/21/2021. First Aid kit was complete. Carbon monoxide/smoke detectors were in working condition.

No issues noted during inspection. LPAs observed that facility is ready to be licensed. This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAU. Additional requirements may still be required.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2021
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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