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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202626
Report Date: 08/23/2023
Date Signed: 08/23/2023 12:40:00 PM

Document Has Been Signed on 08/23/2023 12:40 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: 6DATE:
08/23/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Corey EbadatTIME COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to open a complaint investigation. During visit, a case management deficiencies visit was conducted due violations observed. LPA met with Licensee, Corey Ebadat.

During visit, LPA was sitting at the dining room table and observed resident (R1) open the centrally stored medication cabinet, grab a cub of pre-poured medication, and self administer the cup of medication while staff (S1) was sitting in the kitchen eating a meal. S1 stated to have prepared R1's medication this morning but R1 was not able to take the medication earlier this morning due to a medical appointment.

LPA observed the medication cabinet was unlocked. LPA spoke with staff (S2) who states the medication cabinet should always be locked and they unlock the cabinet if a resident needs medication.

At 11:15am, LPA entered 3 resident bedrooms with staff (S2). LPA observed 3 resident (R2 - R4) beds contained full length bed rails. Based on interview, the staff utilize the full-length bed rails during the night for safety reasons. LPA reviewed R2 - R4's files and did not observe a physician's order and any information in their IPP or appraisal/needs regarding the use of full-length bed rails. Licensee was advised.

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

This report was reviewed with Licensee, Corey Ebadat and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2023
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 08/23/2023 12:40 PM - It Cannot Be Edited


Created By: Christine Dolores On 08/23/2023 at 11:54 AM
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 # 5
FACILITY NUMBER: 435202626

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/24/2023
Section Cited
CCR
87465(h)(2)

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(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
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Licensee will submit a statement of understanding of Title 22 Section 87465(h)(2) to LPA Dolores by POC due date.
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Based on observation and interview the licensee did not ensure the centrally stored medication cabinet was locked and inaccessible to residents in care which poses an immediate health, safety, and personal rights risk to persons in care.
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Type A
08/24/2023
Section Cited
CCR87608(a)(5)(B)

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(5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.
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During visit, Licensee contacted the home health agency regarding the physician's orders on the full length bed rails. Licensee will submit a statement of understanding of Title 22 Section 87608 and a written plan to LPA by POC due date.
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Based on observation, interview, and record review 3 out of 3 residents are utilizing full length bed rails during the night without prior approval from the Department and physician's orders on file which poses an immediate health, safety, and personal rights risk to persons in care.
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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: 08/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2023


LIC809 (FAS) - (06/04)
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