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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202866
Report Date: 03/05/2025
Date Signed: 03/26/2025 08:31:30 AM

Document Has Been Signed on 03/26/2025 08:31 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 #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:
03/05/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:40 AM
MET WITH:Shujen Mae Collado Designated AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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On 3/5/2025, Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted a unannounced complaint investigation. During this time deficiencies were observed and a case management for deficiencies was conducted and discussed the deficiencies with designated administrator (DADM) Shujen Collado.

During file and record review LPA observed Staff 2 (S2) was not associated to the facility and no application to transfer the criminal background was submitted to CCLD for approval. LPA observed an incident report was not submitted to CCLD for 1 out of 6 resident (R1) for elopement that happened on 1/14/2025.

S2 stated that he/she started working in the facility February 28, 2025, but is associated to a different facility under the same ownership/licensee. DADM stated that S2s application to be associated to the facility has not been submitted to CCLD prior to S2 working at the facility. S2 has a clear criminal background record on file.

Citations are being issued based on the following California Code of Regulations (CCR) Title 22 87355 (e)(2) and 87211(a)(D).

Violation of Section 87355(e) shall result in an immediate assessment of civil penalties of one hundred dollars ($100) per violation per day for a maximum of five (5) days for a total of $500.00.

An exit interview was conducted with DADM Shujen Collado, a copy of the report and appeals rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2025
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 03/26/2025 08:31 AM - It Cannot Be Edited


Created By: Maria Partoza On 03/05/2025 at 12:30 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: 03/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/05/2025
Section Cited
CCR
87355(e)(2)

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87355 Criminal Record Clearance (e) All individuals...pursuant to Health and Safety Code Section 1569.17(b) shall prior to working... in a licensed facility: (2)Request a transfer of a criminal record clearance...This section is not met as evidenced by:
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DADM stated that S2s application will be submitted to CCLD within 24 hours.
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Based on interview & record review, DADM stated S2 started working at the facility on 2/28/2025 and application to transfer or associate S2 has was not submitted to CCLD prior to S2 working at the facility which pose/poses an immediate health and personal right risks to persons in care.
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Type B
03/05/2025
Section Cited
CCR87211(a)(D)

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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency... reports... (1) A written report shall be submitted to the licensing agency and to the person responsible…within seven days of the occurrence...(D)Any incident which threatens the welfare,
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con't. safety or health of any resident, such as…unexplained absence of any resident.
This section is not met as evidenced by:
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Based on the interview and record review, DADM stated that incident report of R1s elopement incident on 1/15/25 was not submitted to CCLD and to person responsible for resident within 7 days, which pose/poses a health, safety & personal rights risk to persons in care.
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DADM stated incident reports will be submitted in a timely manner to CCLD and responsible party within seven days of the occurrence.
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: 03/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2025


LIC809 (FAS) - (06/04)
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