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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202866
Report Date: 09/09/2022
Date Signed: 09/09/2022 04:03:36 PM

Document Has Been Signed on 09/09/2022 04:03 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:EBADAT RESIDENTIAL CARE HOME #6FACILITY NUMBER:
435202866
ADMINISTRATOR:EBADAT, HASSANFACILITY TYPE:
740
ADDRESS:697 GLENBURRY WAYTELEPHONE:
(408) 334-8995
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 6CENSUS: 0DATE:
09/09/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Corey EbadatTIME COMPLETED:
11:59 AM
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Licensing Program Analyst (LPA) Steve Chang conducted a pre licensing inspection visit, and met with Licensee (LNS) Corey Ebadat. ADM toured the facility inside out with LNS. There was no COVID poster at the main door. There was no screening station at the main entrance. LNS stated LNS will put the COVID posters at the main entrance and in the facility in 3 days. LNS stated LNS will set up the screening station with COVID questionnaires, guest log book, thermometer, masks, hand sanitizers and gloves in 3 days.

LPA inspected living room, kitchen, dinning area, and laundry room. Medication closet, knives closet, and cleaning product closet were observed locked. No poster of washing hands for 20 seconds were observed by the sink in kitchen. LNS stated LNS will put the poster of washing hands for 20 seconds on by the sink in kitchen. There are 2 single rooms for residents, two shared rooms for residents and one staff live-in room in facility. 2 bathrooms were inspected. Non-skid mats were observed in bathrooms. There were no posters of washing hands for 20 seconds by the sinks in the restrooms. LNS stated LNS will put the posters of washing hands for 20 seconds by the sinks in the restrooms in 3 days. Paper towels were observed with holders, Trash cans were observed with covers. Room temperature was observed at 70 degree F, and hot water temperature was observed at 110 degree F.

The facility is equipped with smoke and carbon monoxide detectors. The facility equipped with fire alarm. LNS tested the smoke and carbon monoxide detectors, and they were working fine. LNS tested the fire alarm, and it was working fine. The fire extinguishers were observed on service on 03/29/2022. LPA inspected the backyard, there was no obstruction to block the walkway.

Component III were conducted with LNS by LPA.

No citation noted during inspection. Exit interview was conducted with LNS. This report was provided to LNS for signature. A copy of this report was provided to LNS.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2022
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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