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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202626
Report Date: 10/29/2021
Date Signed: 10/29/2021 05:03:39 PM

Document Has Been Signed on 10/29/2021 05:03 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 # 5FACILITY NUMBER:
435202626
ADMINISTRATOR:COLLADO, SHU-JENFACILITY TYPE:
740
ADDRESS:734 CHATSWORTH PLTELEPHONE:
(408) 334-8995
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY: 6CENSUS: 5DATE:
10/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Corey EbadatTIME COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required - 1 Year visit and met with Corey Ebadat.

During visit, LPA observed that there was a visitor screening area; however, the screening area did not have forms to record visitor symptoms and temperature. LPA Marrufo toured the facility and observed the facility bathroom was being remodeled. Mr. Ebadat stated that two weeks ago, the floor of the bathroom had a leak underneath it, and Mr. Ebadat hired a contractor to repair the bathroom since last Sunday. The leak also spread to the laundry room, and the floor in the laundry room is being repaired as well. Mr. Ebadat estimates the bathroom and laundry room will be fully repaired within the next three days. LPA Marrufo observed that the laundry room had a commode, which Mr. Ebadat stated was for residents to use. He stated residents are also using the bathroom in the staff bedroom. Mr. Ebadat stated residents are being transported to another facility owned by the licensee that is about 5 minutes away to be showered and have their laundry done. LPA Marrufo consulted with Mr. Ebadat about providing a written plan to licensing about repairing the bathroom and laundry room and about continuing to provide bathroom and laundry services to residents while repairs are being made.

LPA Marrufo observed the food supply and observed there to be a perishable food supply of at least 3 days and a non-perishable food supply of at least 7 days. LPA Marrufo observed there to be a PPE supply of at least 30 days. No deficiencies were made as per California Code of Regulations Title 22. Advisory Notes were issued. See LIC9102 for more information. This report was reviewed with Corey Ebadat and Shu-Jen Collado and a copy of the report was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 10/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2021
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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