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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202626
Report Date: 09/11/2024
Date Signed: 09/11/2024 11:01:21 AM

Unfounded


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
08/15/2023 and conducted by Evaluator Christine Dolores
COMPLAINT CONTROL NUMBER: 26-AS-20230815111504
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:
09/11/2024
UNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Aaron-Dell CoronelTIME COMPLETED:
11:10 AM
ALLEGATION(S):
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Facility staff physically abused resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the finding for the above allegation. LPA met with Administrator, Aaron-Dell Coronel.

On 08/15/2023, the department received the complaint. On 08/23/2023, the initial complaint investigation was conducted.

The following documents were obtained to include resident (R1)’s face sheet, physician’s report, and IPP.

It was alleged that R1 reported that the facility staff physically abused R1.
PAGE 1 OF 2.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024
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 2
Control Number 26-AS-20230815111504
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 # 5
FACILITY NUMBER: 435202626
VISIT DATE: 09/11/2024
NARRATIVE
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On 08/23/2023, 3 staff members were interviewed. Based on interview, 3 out of 3 staff denied physically abusing R1. It was stated that after a meeting with R1, R1’s day program staff, service coordinator and facility staff, R1 admitted on telling a lie.

On 08/23/2023, 2 witnesses were interviewed. Based on interview, 2 out of 2 witnessed stated that after meeting with R1 at the facility, R1 admitted to telling a lie.

On 08/23/2023, R1 was interviewed. Based on interview, R1 denied facility staff hurting R1. R1 admitted to lying about staff hurting R1. R1 stated to feel safe at the facility.

Based on record review, R1 has a history of lying as a means of getting attention.

The Department has investigated the above allegation. Based on interview, record review and observation the above allegation is unfounded, meaning the allegation is 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 Administrator, Aaron-Dell Coronel and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2