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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202403
Report Date: 04/29/2022
Date Signed: 06/09/2022 12:49:59 PM

Document Has Been Signed on 06/09/2022 12:49 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
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: 5DATE:
04/29/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Dodie Arines, ADMTIME COMPLETED:
02:39 PM
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Licensing Program Analyst (LPA) Steve Chang, Licensing Program Manager (LPM) Sarah Yip, and Program Clinical Consultant (PCC) Lori Kopplinger conducted Technical
Assistant - PCC through tele-inspection (Zoom) and met with Administrator (ADM) Dodie Arines.

The purpose of this Technical Assistance (TA) Tele visit was to review the facility COVID-19 infection mitigation plan and conducted inspection of the facility to ensure plan is being carried out and to provide support and guidance to staff in mitigating the spread of virus.

During tele-visit inspection, a tour of the facility was conducted including the main entrance, living room, bedrooms, restrooms, dining room, kitchen, laundry room. Cloth towels were observed in restroom and kitchen. No N95 masks was worn by staff. No COVID signage was posted at the main entrance door. Positive resident was observed not isolating in room. PCC nurse discussed the situation and measures with ADM.

ADM stated all the staff and residents are fully vaccinated and boosted.

Based on today's inspection, below are the recommendations:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 04/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/29/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 #4
FACILITY NUMBER: 435202403
VISIT DATE: 04/29/2022
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1. Facility to remove the cloth towels in restrooms and kitchen.
2. Facility to add the trash cans with foot pedal covers in facility.
3. Administrator to review PINs on isolation and quarantine.
4. Facility to have N95 fitting test for staff who are caring for positive residents.
5. Facility to have hand washing signage that indicate wash for 20 seconds in bathrooms.
6. Facility to conduct staff training at least quarterly or as frequently as needed on
donning and doffing of PPE, COVID -19 updates by CDC, and/or local public
health and to review DSS-CCLD Providers Information Notice (PIN).
7. Facility to update the mitigation plan especially on isolation/quarantine protocol and submit the revised mitigation plan to CCL.
8. Facility to disinfect the high touched areas based on manufacture’s instruction on disinfection.
9. Facility is not to reuse PPEs, but staff need to doff used PPEs after each resident and don new PPE prior to going back to the common area.
10. Facility needs to report timely to LHD via Spot Intake Form.
11. Facility to post signage at the main entrance door.
12. Facility should use the highest temperature for positive residents’ laundry.
13. Facility should not commingle positive individuals with negative individuals in common areas.
14. Staff should be wearing N95 during this outbreak.

No deficiencies cited during today's Tele Visit. Exit interview conducted with ADM.
A copy of this report emailed to ADM for signature.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022
LIC809 (FAS) - (06/04)
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