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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202403
Report Date: 03/23/2022
Date Signed: 03/23/2022 11:18:21 AM

Document Has Been Signed on 03/23/2022 11:18 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, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:EBADAT RESIDENTIAL CARE HOME #4FACILITY NUMBER:
435202403
ADMINISTRATOR:DIOSDADO S. ARINESFACILITY TYPE:
740
ADDRESS:243 MARTINVALE LN.TELEPHONE:
(408) 622-6293
CITY:SAN JOSESTATE: CAZIP CODE:
95119
CAPACITY: 6CENSUS: 6DATE:
03/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Arines DiosdadoTIME COMPLETED:
11:25 AM
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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection on 03/23/2022. LPA met with facility staff member Eileen Calicdan (S1). Administrator Arines Diosdado (Admin) arrived at the facility to review the report after completion of the inspection.

LPA toured the facility, including living room, kitchen, dining room, 4 bedrooms, 2 bathrooms, garage, and back yard. All staff members observed to be wearing masks. Admin confirmed that all staff and residents have been vaccinated.

No prohibited items noted in resident rooms. All emergency exits noted to be clear of obstruction. All rooms in facility noted to be clean and well maintained. Hand sanitizers, soap, and paper supplies were observed to be available. At least 2 days' supply of perishable food and at least 1 week's supply of non-perishable food was observed on the premises. Fire extinguisher observed to be inspected in April 2021.

Facility observed to have designated entry point. Staff took LPA's temperature and screened for symptoms. 30 day supply of PPE was observed. All restrooms stocked with paper towels. Water temperature observed to be 105.1 *F. Hand washing signs were not observed in all bathrooms. Social distancing signs observed to be posted in all public areas.

No deficiencies cited during today's visit. Advisory notes issued. This report was reviewed with facility administrator Arines Diosdado and a copy was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Ryker Heberle
LICENSING EVALUATOR SIGNATURE: DATE: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/23/2022
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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