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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202403
Report Date: 04/04/2023
Date Signed: 04/05/2023 08:05:35 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/06/2023 and conducted by Evaluator Christine Dolores
COMPLAINT CONTROL NUMBER: 26-AS-20230306150707
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: DATE:
04/04/2023
UNANNOUNCEDTIME BEGAN:
05:15 PM
MET WITH:Hassan EbadatTIME COMPLETED:
05:30 PM
ALLEGATION(S):
1
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8
9
Facility not ensuring resident hygiene needs are being met
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the findings of the above allegation. LPA met with Licensee, Ebadat Hassan

On 03/13/2023, the following documents were obtained to include R2 - R3 safeguard cash resources, R1 - R2 and R4 -R5's safeguard of personal property form, and R1's medical records, IPP, admission agreement, and progress notes.

On 03/13/2023, a resident was interviewed. Based on interview, 5 out of 6 residents in the facility are assisted daily with personal hygiene, to include dental hygiene and showers. 1 out of 6 residents who does not require assistance are not given verbal reminders to complete daily personal hygiene. SEE LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 26-AS-20230306150707
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: EBADAT RESIDENTIAL CARE HOME #4
FACILITY NUMBER: 435202403
VISIT DATE: 04/04/2023
NARRATIVE
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On 03/13/2023, 4 staff were interviewed. Based on interview, the facility assists the residents daily with hygiene needs, to include dental hygiene and showers. 4 out of 4 staff states 6 out of 6 residents are either provided hygiene needs daily and/or reminded daily of the importance of personal hygiene. 4 out of 4 staff state certain resident(s) in the facility refuses to participate in personal hygiene daily.

Based on observation from 03/13/2023, residents present were observed clean and well-groomed with no marking's on the skin, clean clothing, and no foul odor.

Based on record review, resident (R1) has history of not maintaining personal hygiene.

The Department has investigated the above allegation. Based on record review, interview, and observation the above allegation is unsubstantiated meaning that although the allegation is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Licensee, Hassan Ebadat and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/06/2023 and conducted by Evaluator Christine Dolores
COMPLAINT CONTROL NUMBER: 26-AS-20230306150707

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: DATE:
04/04/2023
UNANNOUNCEDTIME BEGAN:
05:15 PM
MET WITH:TIME COMPLETED:
05:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility did not safeguard resident belongings
Facility withholding resident’s cash resources
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the findings of the above allegation. LPA met with Licensee, Ebadat Hassan.

On 03/13/2023, the following documents were obtained to include R2 - R3 safeguard cash resources, R1 - R2 and R4 -R5's safeguard of personal property form, and R1's medical records, IPP, admission agreement, and progress notes.

On 03/13/2023, 4 staff were interviewed. Based on interview, the facility assists the residents with cleaning and laundry. All the residents clothing items and personal properties are labeled. There were no observation or record of resident items that were safeguarded that have gone missing at the facility. SEE LIC9099-C.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 26-AS-20230306150707
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: EBADAT RESIDENTIAL CARE HOME #4
FACILITY NUMBER: 435202403
VISIT DATE: 04/04/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
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32
Based on interview, the facility was not managing any cash resources for resident (R1).

The reviewal of records show the the facility was not entrusted items that were alleged missing. The facility was also was not managing or withholding resident’s cash resources.

The Department has investigated the above allegations and based on record review, interview, and observation the above allegations are unfounded meaning the allegations are false, could not have happened, and/or is without a reasonable basis.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Licensee, Hassan Ebadat and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4