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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202396
Report Date: 01/14/2022
Date Signed: 01/14/2022 04:47:06 PM

Document Has Been Signed on 01/14/2022 04:47 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 #1FACILITY NUMBER:
435202396
ADMINISTRATOR:HASSAN EBADATFACILITY TYPE:
735
ADDRESS:163 PARK DARTMOUTH PL.TELEPHONE:
(408) 225-5721
CITY:SAN JOSESTATE: CAZIP CODE:
95136
CAPACITY: 6CENSUS: 4DATE:
01/14/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Hassan EbadatTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Steve Chang, and Program Clinical Consultant (PCC) Roxane Tangon Technical Assistant - PCC through tele-inspection (Zoom). Met with Administrator (ADM) Hassan Ebadat, and staff Gleen Mesa.

The purpose of this TA PCC Tele visit is to review the facility COVID-19 infection mitigation plan and conducted inspection of the facility to ensure plan is being carried out and to provide support and guidance to staff in mitigating the spread of virus.

During tele-visit inspection, a tour of the facility was conducted which started at the main entrance to check COVID-19 signage and screening procedures. The facility has the COVID-19 posters at the main entrance including screening questionnaire forms, hand sanitizer, face masks, thermometer, glove, and a visitor log book at the screening station.

The facility common areas were inspected such as the kitchen, living room, family room, dinning area, bathrooms were observed. There are 3 resident shared bedrooms, 1 staff live-in bedroom, and 2 bathrooms in facility. Trash cans with covers, paper towels with holders, and washing hands signs by the sinks were observed. The laundry room was observed and inspected. The resident bedrooms were inspected. The beds in the shared rooms were observed in 6 feet apart.

ADM stated all the residents and staff are fully vaccinated. ADM stated all the residents and staff except one staff are finished with booster shots.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 01/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/14/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 #1
FACILITY NUMBER: 435202396
VISIT DATE: 01/14/2022
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Based on today's inspection, the facility is being recommended the following:

1. Facility to wipe and disinfect high touch areas as frequently.

2. Facility to remove the extra chairs in dinning area.

3. Facility to have the dedicated PPE area for isolation room.

4. Facility to ensure that residents' soiled clothing/linens are separated between the positive and negative residents. For drying clothes, it should be in high heat temperature.

5. Please review the reference resources LPA sent by email.

No deficiencies cited during today's Tele Visit. Exit interview conducted with Administrator.
A copy of this report emailed to the facility for signature.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2022
LIC809 (FAS) - (06/04)
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