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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202866
Report Date: 08/04/2025
Date Signed: 08/04/2025 04:42:22 PM

Document Has Been Signed on 08/04/2025 04:42 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:		COLLADO, SHUJENFACILITY TYPE:
740
ADDRESS:697 GLENBURRY WAYTELEPHONE:
(408) 334-8995
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 6CENSUS: 6DATE:
08/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:38 PM
MET WITH:Administrator Shujen ColladoTIME VISIT/
INSPECTION COMPLETED:
04:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator Shujen Collado. During the visit, LPA observed 6 residents and 3 staff. LPA explained the purpose of the visit. Ebadat Residential Care Home #6 is a level 4i home.

LPA toured the facility inside out with ADM which included the Living room, kitchen, dining room, 3 restrooms and 4 residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected. There was no obstruction to block the walkways.

Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 73 degrees F, and hot water temperature was measured at 109 degrees F in resident bathrooms.

Fire extinguisher was serviced in August 2025. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on August 20, 2024.

LPA reviewed facility records for 3 staff and 3 residents. LPA asked for Staff S1's completed health screening form was. LPA pointed out S1's health screening did not have the evaluation of general health/ evaluation of ability to preform work / note any health condition/ the physician's stamp/signature. ADM stated S1 would get a new updated health screening in 1 week. Page 1 Out of 3.
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2025
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 6
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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 #6
FACILITY NUMBER: 435202866
VISIT DATE: 08/04/2025
NARRATIVE
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LPA reviewed 3 resident medications and centrally stored medication records. LPA reviewed 3 resident P&I records.

While touring the facility office, LPA observed two partition walls and an additional door. These two walls and door way isn't reflected on the facility sketch. LPA observed in inside the partitioned bedroom a staff member. ADM stated two staff members use the office as a sleeping area. LPA also noted that a staff member was sleeping in the office area.

LPA spoke to Licensee (LN) Kourosh Ebadat. LN stated he just got a permit approval in May 2025, to convert it to a two bedroom, 1 bath ADU. LN confirmed that there are two staff sleeping in the office. LN confirmed the additional bedroom in the office area, at its current state does not have a permit.

While touring the sitting room, LPA observed, a partition wall. Note, this partition is not noted on the facility fire clearance. Furthermore, the fire clearance notes an opening between the sitting room and the living room. Based on empirical observation, there is a wall between both rooms.

LN stated the sitting room-living room did not have an opening for crossing. LN stated there was a slight opening approximately 3 feet tall, and 8 foot wide. LN stated he did block that opening. LN also confirmed he did put a partition - half wall in the sitting room.

LPA toured the facility shed in the backyard. LPA noted there was a mattress, cloths, medications. LPA also observed a power cord from the facility, heading inside the shed. LPA also noted there was a fan, a heater pointed towards the bed inside the storage shed. ADM confirmed there is a staff who sleeps in the shed.

LPA provided ADM with copy of PIN 25-08-ASC.

Page 2 Out of 3.
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2025
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 08/04/2025 04:42 PM - It Cannot Be Edited


Created By: Manuel Monter On 08/04/2025 at 03:55 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: 08/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation & record review, the licensee did not comply with the section cited above. Based on observation, facility shed in the backyard. LPA noted there was a mattress, cloths, medications, with a power cord inside.LPA also noted there was a fan, a heater pointed towards the bed. ADM confirmed there is a staff who sleeps in the shed. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/11/2025
Plan of Correction
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LN stated he will remove all personal belongings, and ensure the facility shed is being used as stoarge only. LN stated he will send LPA photo documenation showing the shed in the backyard is only being used as a storage space.
Type B
Section Cited
CCR
87305(a)
Alterations to Existing Buildings or New Facilities
(a) Prior to construction or alterations, all facilities shall obtain a building permit.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation,interview, record review, the licensee did not comply with the section cited above. Based on observation, the facility office and sitting room does not reflect the current facility fire cleareance. LN confirmed he did add a partition wall in the sitting room. LN confirmed the additional bedroom in the office does not have a permit. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/11/2025
Plan of Correction
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LN stated he has already obtained a permit to demolish and rebuild the office. LN stated once it has been completed, he will inform licensing. LN stated, he will get a permit for the partiton wall for the inbetween area of the living room and sitting room. LN stated he will either get a permit to keep the wall, by POC date, August 11, 2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:
Manuel Monter
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2025


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 08/04/2025 04:42 PM - It Cannot Be Edited


Created By: Manuel Monter On 08/04/2025 at 03:55 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: 08/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. S1's health screening did not have the evaluation of general health/ evaluation of ability to preform work / note any health condition/ the physician's stamp/signature. ADM stated S1 would get a new updated health screening in 1 week. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/11/2025
Plan of Correction
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ADM stated S1 will complete a new health screening. ADM stated she will send LPA a copy of the updated health screening to LPA by POC date, August 11, 2025.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Based on a review of the facility's disaster drill log, the last drill conducted was on August 20, 2024. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/11/2025
Plan of Correction
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LN stated they will conduct a drill. LN stated he will send documenation showing a drill has taken place. LN stated he will send a letter of understanding regarding the regulation. LN stated he will send the POC letter to LPA by POC date, August 11, 2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:
Manuel Monter
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2025


LIC809 (FAS) - (06/04)
Page: 5 of 6
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: 08/04/2025
NARRATIVE
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LPA requested copies of the following forms: 1. LIC500, Personnel Summary
2. LIC308, Designation of Administrative Responsibility 3. LIC400, Affidavit Regarding Client/Resident Cash Resources 4. Liability Insurance 5. LIC200, please update (i.e., new phone numbers etc), if necessary.
6. Qualifications of Administrator (Certificate) 7. Please review your facility program for updates (incorporating new laws and/or regulations) 8. LIC309, Administrative Organization

Deficiencies cited during today's visit, see LIC809-D. This report was reviewed with Licensee (LN) Kourosh Ebadat. and a copy of the signed report was provided. Appeal rights were provided.

Page 3 Out of 3. END OF REPORT.
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2025
LIC809 (FAS) - (06/04)
Page: 6 of 6