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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202396
Report Date: 12/27/2022
Date Signed: 12/27/2022 05:00:46 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 12/27/2022 05:00 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:AARON-DELL CORONELFACILITY TYPE:
735
ADDRESS:163 PARK DARTMOUTH PL.TELEPHONE:
(408) 225-5721
CITY:SAN JOSESTATE: CAZIP CODE:
95136
CAPACITY: 6CENSUS: 5DATE:
12/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:39 PM
MET WITH:Gleen Mesa, HMTIME COMPLETED:
04:10 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection, and met with House Manager (HM) Gleen Mesa.

Upon Arrival, HM took LPA's body temperature, and checked LPA in the visitor log book. LPA observed the COVID posters in the facility. Two staff and six residents were observed in facility.

LPA toured the facility with HM inside and out. LPA inspected living room, family room, dinning area, kitchen. There are 2 restrooms, 1 staff live-in room, and 3 resident rooms in facility. Trash cans was observed with covers. Posters of washing hands for 20 seconds by the sinks in restrooms and kitchen. Two days perishable foods and seven day nonperishable foods were observed sufficient. PPE supplies were observed sufficient. Room temperature was observed at 72 degree F, hot water temperature was observed at 110 degree F. Medication cabinet, Knife closet were observed locked. Cleaning products closet was observed locked. The facility was equipped with smoke and carbon monoxide detectors. Smoke detector alarm system was tested, and was working fine. Fire extinguisher was serviced on 4/18/2022. Front yard and backyard were inspected. There was no obstruction to block the walkways.

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

No citation was issued today. Exit interview was conducted with HM. This report was provided to HM for signature. A copy of this report was provided to HM.
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)
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