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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202504
Report Date: 06/19/2024
Date Signed: 06/19/2024 04:09:23 PM


Document Has Been Signed on 06/19/2024 04:09 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:SELLECK, TIMFACILITY TYPE:
741
ADDRESS:401 WEBSTER STREETTELEPHONE:
(650) 327-4333
CITY:PALO ALTOSTATE: CAZIP CODE:
94301
CAPACITY:54CENSUS: 42DATE:
06/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Kris VuTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Kris Vu, Director of Resident Health Services..

During visit, LPA Marrufo toured the facility inside and out. During visit, LPA Marrufo toured the facility kitchen area. LPA observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA Marrufo reviewed the facility first aid kit and found it to be complete.

LPA Marrufo reviewed the Centrally Stored Medication and Destruction Record (CSMDR) for residents R1-R5. Resident R1 had two prescription medications that were not entered into the CSMDR. R2 had six prescription medications that were not in the CSMDR. R3 had three prescription medications that were not in the CSMDR. R4 had 3 prescription medications that were not in the CSMDR. R5 had 1 medication that was not in the CSMDR. LPA Marrufo reviewed the resident records for R1-R5 and found them to be complete. LPA Marrufo reviewed the staff records for staff S1-S6. Staff S4-S6 did not have current first aid certifications on file. Staff S2, S4, S5, and S6 were missing their LIC9025 Employee Rights Forms in their staff records. LPA Marrufo toured 1 hallway bathroom and 5 resident living units. The hallway bathroom and the bathrooms in the living units each had working lights and available soap and paper towels. The water temperatures in all toured bathrooms were between 112 F and 115 F. The bedrooms in each living unit had available bedding and clothing storage areas and working lights. LPA Marrufo toured the outside area and found the exits to be clear of obstructions and the pool area was locked. Per facility records, the Smoke Detector System was last tested on 04/18/2024 and the last fire drill was done on 03/22/2024.

Deficiencies were cited as per California Code of Regulations Title 22. See LIC809-D for more information. An Advisory Note was issued. See LIC9102 for more information. This report was reviewed with Kris Vu and a copy of this report and appeal rights were provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2024
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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Document Has Been Signed on 06/19/2024 04:09 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOUSE
FACILITY NUMBER: 435202504

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
87411 Personnel Requirements – General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above in 3 out of 6 reviewed staff records, which were missing current first aid ceritifications, which poses a potential safety risk to persons in care.
POC Due Date: 06/26/2024
Plan of Correction
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Licensee agrees to submit current First Aid Certifications for staff S4-S6 to CCL by POC date.
Type B
Section Cited
CCR
87465(h)(6)(A)-(F)
87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: (A) The name of the resident for whom prescribed. (B) The name of the prescribing physician. (C) The drug name, strength and quantity. (D) The date filled. (E) The prescription number and the name of the issuing pharmacy. (F) Instructions, if any, regarding control and custody of the medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above in 5 out of 5 reviewed resident Centrally Stored Medication and Destruction Records (CSMDR), which had prescription medications which were missing from the CSMDR, which poses a potential health risk to persons in care.
POC Due Date: 06/26/2024
Plan of Correction
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Licensee agrees to audit and update all resident Centrally Stored Medication and Destruction Records (CSMDR) and, once completed, submit a Statement of Correction to CCL by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2024
LIC809 (FAS) - (06/04)
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