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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202403
Report Date: 04/04/2023
Date Signed: 04/04/2023 05:11:29 PM

Document Has Been Signed on 04/04/2023 05:11 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: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:
04/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:TIME COMPLETED:
05:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual inspection. LPA met with Licensee, Hassan Ebadat.

During visit, LPA toured the facility to include the living room, dining room, kitchen, resident bedrooms, bathroom, staff bedroom, garage, and backyard. All fire exit routes were free and clear of obstruction. All staff present are fingerprint cleared and associated to the facility.

Facility temperature maintained at 71 degrees Fahrenheit. Hot water temperature maintained at 123 degrees Fahrenheit. Facility's fire extinguisher last serviced on 04/18/2022. LPA observed the facility's carbon monoxide detector.

Bedrooms contained proper furniture, lighting, and linens. Bathrooms supplied with paper supplies, lidded trash bins, hygiene products, and hand washing sign. LPA observed the facility's food supply. LPA advised Licensee to ensure the refrigerator and freezer has a thermometer to maintain proper temperature. LPA advised to ensure prepared foods are properly labeled.

LPA reviewed 5 residents files. LPA observed the residents appraisal needs and services plans were last updated in year 2019. LPA advised to ensure resident's appraisal needs and services plan are reviewed and updated yearly and as often as necessary, to ensure accuracy. LPA observed residents medical assessments were not up to date for residents diagnosed with Dementia. Licensee was advised.

SEE LIC809-C.
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.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/04/2023 05:11 PM - It Cannot Be Edited


Created By: Christine Dolores On 04/04/2023 at 04:34 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: EBADAT RESIDENTIAL CARE HOME #4
FACILITY NUMBER: 435202403

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87208(a)
Plan of Operation
(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review the licensee did not ensure to maintain the facility's plan of operation / dementia plan of operation on file in the facility for licensing review which poses a potential health, safety, and personal rights risk to persons in care.
POC Due Date: 04/11/2023
Plan of Correction
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Licensee will ensure to maintain the facility's plan of operation in the facility. Licensee will submit a statement of understanding of the section cited above to LPA by POC due date.
Type B
Section Cited
HSC
1569.625(c)(8)
Other Provisions
(c) The training shall include, but not be limited to, all of the following: (8) The special needs of persons with Alzheimer’s disease and dementia, including nonpharmacologic, person-centered approaches to dementia care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review the licensee did not ensure staff are trained on dementia care while retaining residents with dementia which poses a potential health, safety, and personal rights risks to persons in care.
POC Due Date: 04/11/2023
Plan of Correction
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Licensee will ensure to train all staff on dementia care. Licensee will submit the training documentation to LPA by POC due 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 Yip
LICENSING EVALUATOR NAME:Christine Dolores
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2023


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 04/04/2023 05:11 PM - It Cannot Be Edited


Created By: Christine Dolores On 04/04/2023 at 04:34 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: EBADAT RESIDENTIAL CARE HOME #4
FACILITY NUMBER: 435202403

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)
Resident Records
(b) Each resident's record shall contain at least the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review the licensee did not ensure the residents files were up to date to contain all required documents which poses a potential health, safety, and personal rights risk to persons in care.
POC Due Date: 04/11/2023
Plan of Correction
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Licensee will review LIC858 provided by LPA. Licensee will ensure residents files contain all required documents listed in this section. Licensee will review section 87506 and submit a statement of understanding to LPA by POC due date.
Type B
Section Cited
CCR
87463(c)
Reappraisals
(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review the licensee did not ensure residents appraisal needs and services plans were updated yearly and as often as needed to ensure accuracy which poses a potential health, safety, and personal rights risk to persons in care.
POC Due Date: 04/11/2023
Plan of Correction
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Licensee will review section 87463 and submit a plan to update all residents appraisal needs and services plan to LPA by POC due 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 Yip
LICENSING EVALUATOR NAME:Christine Dolores
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2023


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
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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LPA reviewed 4 staff files and training records. Staff obtain an updated first aid certification. Emergency Drill training was conducted on in March 2023.

Facility retain residents who are diagnosed with Dementia. LPA did not observe staff are trained in caring for a persons with Dementia. Facility did not have their plan of operations maintained at the facility.

Facility has their emergency disaster plan posted at the front entrance. LPA did not observe the facility have proper supplies that are ready in case of an emergency or disaster.

The following posters observed to include the ombudsman, licensing complaint poster, personal rights, facility sketch, and COVID-19 related posters.

Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D and LIC9102.

A plan of correction was developed with Licensee, Hassan Ebadat. A copy of this report and appeal rights were 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
LIC809 (FAS) - (06/04)
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