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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202626
Report Date: 09/11/2024
Date Signed: 09/11/2024 11:02:24 AM

Document Has Been Signed on 09/11/2024 11:02 AM - 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/
DIRECTOR:		CORONEL, AARON-DELLFACILITY TYPE:
740
ADDRESS:734 CHATSWORTH PLTELEPHONE:
(408) 334-8995
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY: 6CENSUS: 6DATE:
09/11/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:25 AM
MET WITH:Aaron-Dell CoronelTIME VISIT/
INSPECTION COMPLETED:
11:10 AM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the complaint finding for complaint control number: 26-AS-20230815111504. During visit, a violation was observed prompting a case management visit. LPA met with Administrator, Aaron-Dell Coronel.

During visit, LPA observed a staff (S1) who is not fingerprint cleared. Based on record review, S1 has a request for live scan form dated May 2024 and DOJ Applicant fingerprint Response dated May 16, 2024. LPA Dolores used the Guardian system to search for S1’s background check. The search results stated, “no applicants that match your search criteria were found in the background check system”. LPA also called the Licensing office and confirmed with a support staff that S1 does not have a background check application.

Based on an interview with the Administrator, the Administrator thought the “DOJ Applicant fingerprint Response” was the background check clearance. LPA did not observe S1 received a clearance notification from the Department. LPA advised Administrator to verify staff’s fingerprint clearance through Guardian or by calling the Licensing office to confirm. Administrator stated understanding.

A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D. A civil penalty was assessed for the amount of $500 ($100 x 5 days = $500) for S1 working in the facility without a fingerprint clearance.

This report was reviewed with Administrator, Aaron-Dell Coronel and a copy of the report and appeal rights were 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
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 09/11/2024 11:02 AM - It Cannot Be Edited


Created By: Christine Dolores On 09/11/2024 at 10:37 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: 09/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/12/2024
Section Cited
CCR
80019(e)(2)

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(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (2) Obtain a California clearance or a criminal record exemption as required by the Department or
This requirement is not met as evidenced by:
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Licensee plans to request another live scan for S1. Licensee will submit a written plan when verifying new staff's personnel records to include their fingerprint clearance, to LPA Dolores via email by POC due date.
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Based on interview, record review and observation the licensee did not ensure staff (S1) obtained a fingerprint clearance from the Department prior to working in the facility 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: 09/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2024


LIC809 (FAS) - (06/04)
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