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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202380
Report Date: 12/11/2024
Date Signed: 12/11/2024 04:26:12 PM

Document Has Been Signed on 12/11/2024 04:26 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 #3FACILITY NUMBER:
435202380
ADMINISTRATOR/
DIRECTOR:		AARON CORONELFACILITY TYPE:
735
ADDRESS:4243 ROSENBAUM AVE.TELEPHONE:
(408) 224-3716
CITY:SAN JOSESTATE: CAZIP CODE:
95136
CAPACITY: 6CENSUS: 6DATE:
12/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:Aaron CoronelTIME VISIT/
INSPECTION COMPLETED:
12:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with administrator (ADM) Aaron Coronel.

LPA observed 2 staff in the facility. 4 residents went to day program, 1 resident went to dental appointment, and 1 resident went to work.

LPA reviewed 3 resident files and 3 staff files. License, ADM certificate and personal rights posters were observed at the main entrance.

Living room, kitchen, and family room were inspected. Three shared resident bedrooms, and two bath rooms were inspected. One staff live-in room was observed in the facility. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. The temperature of the refrigerator was observed at 38 degree F, and the temperature of the freezer was observed at 0 degree F. Knives closet and medication closet were observed locked. Cleaning product closet was observed unlocked, ADM locked the cleaning product closet immediately. Room temperature was observed at 68 degree F. Hot water was observed at 110 degree F.

Fire extinguisher was serviced on 04/15/2024. The facility was equipped with smoke and carbon monoxide detectors, and fire alarm. Carbon monoxide detectors were tested and were working. First aid box flash lights were observed at the facility. The last time of the facility earthquake drill was on 6/5/2024 and the last time fire drill was on 6/3/2024. Front yard and backyard were inspected. One storage room was observed at the backyard. There was no obstruction observed to block the walkways.

Citation noted today. See LIC809-D. 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: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2024
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 12/11/2024 04:26 PM - It Cannot Be Edited


Created By: Chihhsien Chang On 12/11/2024 at 11:48 AM
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 #3
FACILITY NUMBER: 435202380

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(b)(14)
Client Records
(b) Each record must contain information including, but not limited to, the following: (14) An account of the client's cash resources, personal property, and valuables entrusted as specified in Section 80026.

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 in that 1 Out of 3 resident files was found the resident R1's P & I money was not matched with the transaction log balance which poses/posed a potential personal rights risk to persons in care.
POC Due Date: 12/18/2024
Plan of Correction
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Administrator stated to submit a plan of correction to ensure the facility maintains accurate P & I money transaction log. ADM stated to provide staff training to ensure staff maintain accurate resident P & P money transaction log.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:
DATE: 12/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2024


LIC809 (FAS) - (06/04)
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