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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 11:39:33 AM

Document Has Been Signed on 10/11/2021 11:39 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:Case Management - OtherANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Pia Webster, AdministratorTIME COMPLETED:
11:45 AM
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On 10/11/2021 at 10:50 AM, Licensing Program Analysts, (LPAs), C, Fowler and L. Hall arrived to conducted a Component III presentation. LPAs met with Administrator, Pia Webster.

LPAs presented the Component III power point and discussed the regulations embodied in the power point. LPA observed the participant gained knowledge about running and maintaining the facility in accordance with regulations.

Exit interview conducted with Administrator, Pia Webster. And copy provided 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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