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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202396
Report Date: 12/11/2024
Date Signed: 12/12/2024 05:00:32 PM

Document Has Been Signed on 12/12/2024 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:EBADAT RESIDENTIAL CARE HOME #1FACILITY NUMBER:
435202396
ADMINISTRATOR/
DIRECTOR:		GLEEN MESAFACILITY TYPE:
735
ADDRESS:163 PARK DARTMOUTH PL.TELEPHONE:
(408) 225-5721
CITY:SAN JOSESTATE: CAZIP CODE:
95136
CAPACITY: 6CENSUS: 4DATE:
12/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:50 PM
MET WITH:Gleen MesaTIME VISIT/
INSPECTION COMPLETED:
03:59 PM
NARRATIVE
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection, and met with Administrator (ADM) Gleen Mesa.

LPA observed 2 staff. All residents went to day program.

LPA reviewed 2 resident files and 2 staff files.

LPA observed licensee, Administrator Certificate, and personal rights posters at the main entrance.

LPA toured the facility with ADM 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 the facility. Two days perishable foods and seven day nonperishable foods were observed sufficient. Room temperature was observed at 72 degree F, hot water temperature was observed at 118 degree F. Medication cabinet, knives closet were observed locked. Cleaning products for washing dish was observed not locked, ADM locked it immediately. The facility was equipped with fire alarm, smoke and carbon monoxide detectors. Carbon monoxide detector was tested, and was working fine. Fire extinguisher was serviced on 4/25/2024.

LPA observed the garage was under construction. The garage is converting to two staff rooms and one restroom. The facility did not notify CCL office that the facility conducts alteration/conversion and construction. LPA called licensee, licensee stated the facility has city permit for the construction and the facility will notify CCL office after the construction completes. LPA told licensee that the facility should notify CCL office prior to conduct the conduction. ADM provided the city permit to LPA.

Continue on LIC809-C. Page 1 of 2.
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)
Page: 1 of 3
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 #1
FACILITY NUMBER: 435202396
VISIT DATE: 12/11/2024
NARRATIVE
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Deficiency noted for the facility did not notify CCL office prior to the alteration/conversion of the existing building.

LPA told ADM to provide plan of action to ensure the health and safety of residents for the facility's new construction. LPA requested the facility to provide the new facility sketch.

The last time the facility conducted the fire drill was on 10/4/2024. First aid box, night light, flash lights were observed at the facility.

Front yard and backyard were inspected. There was no obstruction to block the walkways.

Citation was issued 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.


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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
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 12/12/2024 05:00 PM - It Cannot Be Edited


Created By: Chihhsien Chang On 12/11/2024 at 03:03 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 #1
FACILITY NUMBER: 435202396

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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80086(a)

80086 Alteration to Existing Building or New Facilities (a) Prior to construction or alterations, all licensees shall notify the licensing agency of the proposed change.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in that the during LPA's inspection visit, LPA observed the garage was under construction and the garage was converiting to 2 staff bedrooms and 1 restroom. The facility did not notify CCL office that the facility to convert the garage to 2 staff bedrooms and 1 restroom. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2024
Plan of Correction
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Administrator stated to send a plan of correction by the POC due date to ensure licensee and administrator to understand the title 22 regulations that the facility shall notify CCL office prior to any new construction for the facility. Administrator to submit the facility new floor map, the city permit, and plan of action on how to ensure the heakth and safety of the residents during the new construction of the facility.
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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