<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202504
Report Date: 08/03/2022
Date Signed: 08/03/2022 04:25:18 PM


Document Has Been Signed on 08/03/2022 04:25 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



FACILITY NAME:WEBSTER HOUSEFACILITY NUMBER:
435202504
ADMINISTRATOR:HIBBS, LINDAFACILITY TYPE:
741
ADDRESS:401 WEBSTER STREETTELEPHONE:
(650) 327-4333
CITY:PALO ALTOSTATE: CAZIP CODE:
94301
CAPACITY:54CENSUS: 33DATE:
08/03/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Tim SelleckTIME COMPLETED:
04:35 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Tim Selleck. The Case Management visit was in response to a Suspected Adult/Elderly Abuse form (SOC341) that the facility submitted to licensing alleging that staff S1 verbally abused resident R1.

During visit, LPA Marrufo interviewed resident R1 as well as residents R2-R7. LPA Marrufo interviewed staff S1 and staff S2-S5, as well as Administrator Tim Selleck. LPA Marrufo obtained copies of R1's Admission Record, Physician's Report, and Appraisal/Needs and Services Plan. LPA Marrufo obtained copies of the Resident Roster, Staff Schedule, and Internal Investigation Report that the facility conducted in response to the incident, Training Certification Record for S1, and In-Service Training Record for Emergency Pendant Response Time dated 7/13/2022 for all staff.

The Internal Investigation Report stated that the response plan for the facility will be to always have another staff accompany S1 when assisting R1.

No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Administrator Tim Selleck and a copy of the report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2022
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 1