<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202866
Report Date: 09/21/2024
Date Signed: 09/21/2024 05:38:09 PM

Document Has Been Signed on 09/21/2024 05:38 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 #6FACILITY NUMBER:
435202866
ADMINISTRATOR/
DIRECTOR:		EBADAT, HASSANFACILITY TYPE:
740
ADDRESS:697 GLENBURRY WAYTELEPHONE:
(408) 334-8995
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 6CENSUS: 6DATE:
09/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Shu Jen Collado - AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Maria (Mita) Partoza a conducted an unannounced required 1 year inspection visit and met with administrator Shu Jen Collado and stated the purpose of the visit.

The facility is licensed to serve adults 60 and over of which 3 may be non-ambulatory. LPA observed 5 out of 6 residents are present at the facility that have neurocognitive impairment, 3 staff (S1 to S3) were present and attending to residents.

At 2:00 p.m. LPA toured the facility inside and outside with S1 including but not limited to the kitchen, bathroom, dining room, living room, 4 residents rooms, office/bedroom and laundry area backyard and exterior walkways. The temperature inside the home was at 73 degrees Fahrenheit.

The kitchen was observed to be sanitary and organized, knives and sharps were locked and not accessible to residents. LPA observed 2 days of perishable food and 7 days of non-perishable food. Under the sink cabinet is used to store pots and pans. The kitchen water temperature measured at 114.6 degrees Fahrenheit.

The facility is maintained, sanitary. The bathrooms are equipped with grab bars, non-skid mats. The water temperature in the bathroom measured between 114.6 degree Fahrenheit. Resident's room (R1 to R6) have sufficient storage, organized and sanitary. LPA observed that medications are kept locked and inaccessible to residents. The first aid kit is complete and is accessible to staff.

The backyard, walkways, ramps and patio are free from debris and obstruction. The facility screen windows were observed to be in good repair. The washer and dryer are in god working condition. Laundry soap and cleaning supplies are locked and not accessible to residents in care.
page 1 of 2
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE: DATE: 09/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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 #6
FACILITY NUMBER: 435202866
VISIT DATE: 09/21/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The facility is equipped with a fire, smoke and carbon monoxide alert system that is in good working condition, night lights on the hallway are in good working condition. The hallway are free from obstruction.

LPA reviewed 3 out of 6 resident records such as but not limited to the centrally stored medication and destruction record (CSMDR), admission agreement, needs and services plan, health screening and observed records the following; 2 out 3 (R1 to R3) were missing consent form, appraisal needs and services plan. R1 to R3 are missing information on the personal rights document. R1-R3 are missing information on the emergency ID. R3 is missing the second page of the physicians medical report.

LPA reviewed 4 out of 8 staff records including but not limited to required training, first aid/CPR training, health screening and background clearance. 4 out 8 (S1 to S5) staff have criminal record clearance/fingerprints that are completed and updated. 1 out of 8 staff (S5) started at the facility 9/1/2024 and has criminal background/fingerprint clearance. Licensee stated, he/she is in the process of transferring the criminal record clearance of S5. LPA was able to verify eligibility of S5 through Guardian. S5 was observed providing care and supervision to residents in care.

Deficiency is cited during today's visit base on California Code of Regulation (CCR) Title 22 87355(c)(1) and
87506(a). An exit interview was conducted with administrator Shu-Jen Collado. A copy of the report and appeals rights were provided.

page 2 of 2
end of report
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 09/21/2024 05:38 PM - It Cannot Be Edited


Created By: Maria Partoza On 09/21/2024 at 05:08 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 #6
FACILITY NUMBER: 435202866

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87355(c)(1)
87355 Criminal Record Clearance (c) A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another…by providing the following documents to the Department: (1) A signed Criminal Background Clearance Transfer Request, LIC 9182 (Rev. 4/02) This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not transfer criminal record clearance of S5 from one facility to another. S5 was observed providing care and supervision to residents in care which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/23/2024
Plan of Correction
1
2
3
4
Licensee stated that he/she is working on the transfer of S5's criminal record clearance and will submit proof of submission and transfer of records to LPA by the due date.
Type B
Section Cited
CCR
87506(a)
87506 Resident Records (a)The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location… readily available … to licensing agency staff. This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review the licensee did not by not completing, maintaining the record of 3 out of 6 resident records. 2 out 3 (R1 to R3) were missing consent form, appraisal needs and services plan. R1 to R3 are missing information on the personal rights document. R1-R3 are missing information on the emergency ID. R3 is missing the second page of the physicians medical report, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/21/2024
Plan of Correction
1
2
3
4
The licensee and adminsitrator stated they will complete the information on the resident's record and will send LPA proof of completion by POC due date.
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:Maria Partoza
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2024


LIC809 (FAS) - (06/04)
Page: 3 of 3