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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202626
Report Date: 10/25/2022
Date Signed: 10/25/2022 03:35:01 PM

Document Has Been Signed on 10/25/2022 03:35 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 # 5FACILITY NUMBER:
435202626
ADMINISTRATOR:COLLADO, SHU-JENFACILITY TYPE:
740
ADDRESS:734 CHATSWORTH PLTELEPHONE:
(408) 334-8995
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY: 6CENSUS: 3DATE:
10/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Shu-Jen ColladoTIME COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual inspection focusing on infection control. LPA met with Administrator, Shu-Jen Collado.

During visit, LPA toured the facility with staff to include the living room, dining room, kitchen, resident rooms, bathroom, laundry room, and backyard. All fire exit routes were free and clear of obstruction.

Facility has a designated entry point for symptom screening and temperature check for all visitors and staff. Hand sanitizer made available at entry. Bathroom supplied with paper products and hygiene products. LPA recommended facility post a hand washing sign in all sink areas. Trash can with lid observed. Facility staff are trained on infection control. Staff clean and disinfect multiple times daily and as needed. Facility has procedures to isolation. LPA observed facility's Personal Protective Equipment (PPE) supplies. Staff are not N95 fit tested. The following posters observed to include special visitors, droplet precaution, hand washing, and symptoms of COVID.

No deficiency was cited per California Code of Regulations, Title 22. Advisory notes provided.

This report was reviewed with Administrator, Shu-Jen Collado and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2022
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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