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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202380
Report Date: 12/27/2022
Date Signed: 12/27/2022 05:01:57 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 12/27/2022 05:01 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 #3FACILITY NUMBER:
435202380
ADMINISTRATOR:JOCELYN REALFACILITY TYPE:
735
ADDRESS:4243 ROSENBAUM AVE.TELEPHONE:
(408) 224-3716
CITY:SAN JOSESTATE: CAZIP CODE:
95136
CAPACITY: 6CENSUS: 6DATE:
12/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Jocelyn RealTIME COMPLETED:
04:50 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) Steve Chang conducted an unannounced annual inspection visit, and met with administrator (ADM) Jocelyn Real. Upon arrival, ADM took LPA body temperature, and logged LPA in the visitor book.

LPA observed the COVID posters at main entrance and in facility. A screening station with face masks, hand sanitizers, gloves and visitor log book was observed at main entrance. Living room, kitchen, and family room were inspected. Four residents were observed in facility. Three shared resident bedrooms, and two bath rooms were inspected. Trash cans were observed with covers. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Knives closet, cleaning product closet, and medication closet were observed locked. Room temperature was observed at 72 degree F. Hot water was observed at 108 degree F.

Fire extinguisher was serviced on 04/18/2022. The facility was equipped with smoke and carbon monoxide detectors, and fire alarm. Front yard and backyard were inspected. There was no obstruction observed to block the walkways.

ADM stated all the staff and residents are fully vaccinated and done the booster shots. ADM already submitted Infection Control Plan to LPA.

No citation were noted today. Exit interview was conducted with ADM. This report was provided to ADM for signature. A copy of this report was provided to ADM.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 12/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/27/2022
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 1