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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202626
Report Date: 10/16/2024
Date Signed: 10/16/2024 05:16:35 PM

Document Has Been Signed on 10/16/2024 05:16 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/
DIRECTOR:		CORONEL, AARON-DELLFACILITY TYPE:
740
ADDRESS:734 CHATSWORTH PLTELEPHONE:
(408) 334-8995
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY: 6CENSUS: 5DATE:
10/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:05 PM
MET WITH:Aaron Dell CoronelTIME VISIT/
INSPECTION COMPLETED:
05:20 PM
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Licensing Program Analyst (LPA) Marcela Yanez and Christine Dolores conducted an unannounced Required 1 Year visit and met with Aaron Dell Coronel Administrator.

During visit, LPAs toured the facility inside and out with staff. 4 resident's observed in the living room area. 5 staff observed present are fingerprint cleared and associated to facility. LPAS toured the outside area and found the exits to be clear of obstructions. LPAs entered the garage area and observed cabinets of non-perishable foods and locked cabinets for cleaning supplies. LPAs observed the garage has a built-in storage room located to the back left of the garage, which the Licensee states was installed about 2 months ago. Licensee states the fire Department visited the facility and stated a permit is not needed as the purpose of the room is for storage.

Facility temperature maintained at 74 degrees F. LPA observed the kitchen area and observed locked cabinets for medications and sharp objects. LPA observed perishable food supply of at least two days and a non-perishable food supply of at least seven days. Refrigerator temperature maintained at 37 degrees F and freezer temperature maintained at -3 degrees F.

LPA entered 3 resident bedrooms. Each bedroom had available bedding and clothing storage areas as well as functioning lights. 2 resident beds observed with full bed rails. LPA toured one resident bathroom. Resident bathroom had available soap, paper towels and functioning lights. Shower equipped with grab bars and non-slid mats. The water temperatures in the bathroom sink measured using a thermometer at 158.0 degrees F. Licensee adjusted the water heater during visit and LPAs measured the hot water temperature using a thermometer to be at 112.1 degrees F.

LPAs observed first aid kit was complete. Facility has flashlights and batteries. LPA observed the fire extinguisher was last serviced on 10/26/2024. Carbon monoxide detector present. LPA reviewed Fire and Earthquake drills was last conducted on 07/2024. Page 1 of 2.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE: DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/16/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/16/2024
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3 resident records were reviewed and observed complete to include the admission agreement, physician's report, TB result, updated needs and services plan and/or IPP, identification and emergency contact information, safeguard of personal properties and valuables, personal rights, and consent forms. 3 residents centrally stored medications and P&I money observed maintained.

Based on record review, 2 resident's who are using full length bed rails does not contain a physician's order for full length bed rails. LPAs observed the physician's orders states the use for side rails, but the order did not indicate if the side rails were for half or full. LPAs reviewed the facility file and the facility did not submit an exception request for the use of full length bed rails. Based on record review, 2 resident's appraisal/needs and services plan and IPP did not include the need for full length bed rails.

LPA reviewed 3 staff records and found them to be complete to include a health screening, TB result, job application, fingerprint clearance and 1st aid certification. 3 staff files contains at least 20 hours of annual training.

Documents were requested to LPA Dolores by 10/17/2024:
- LIC500 (Personnel Report)
- Liability Insurance
- Lease Agreement

Deficiencies were cited as per California Code of Regulations Title 22. This report was reviewed with Administrator, Aaron-Dell Coronell and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 10/16/2024 05:16 PM - It Cannot Be Edited


Created By: Marcela Yanez On 10/16/2024 at 04:48 PM
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: 10/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and observation, the licensee did not comply with the section cited above in wherein the hot water temperature in the bathroom was measured at 158 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/17/2024
Plan of Correction
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Licensee corrected the deficiency during visit by turning down the hot water temperature. Hot water temperature measured at 112.1 degrees F.
Type A
Section Cited
CCR
87608(a)(5)(B)
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (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. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, record review and observation the licensee did not comply with the section cited wherein 2 resident beds contains full length bed rails without a physician's order for the full length beds and approval from the Department which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/17/2024
Plan of Correction
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Licensee will submit a written plan to ensure compliance of the section cited regarding the postural supports to LPA Yanez via email by POC due date of 10/17/2024.
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:Romeo Manzano
LICENSING EVALUATOR NAME:Marcela Yanez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 10/16/2024 05:16 PM - It Cannot Be Edited


Created By: Marcela Yanez On 10/16/2024 at 04:54 PM
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: 10/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review the licensee did not comply with the section cited above in wherein 2 residents appraisal/needs and serices plan did not include the need for full length bed rails which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/23/2024
Plan of Correction
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Licensee will update the appraisal/needs and services plan to include the use of the postural supports via email to LPA Yanez by POC due date of 10/23/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Romeo Manzano
LICENSING EVALUATOR NAME:Marcela Yanez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2024


LIC809 (FAS) - (06/04)
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