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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202403
Report Date: 03/13/2023
Date Signed: 03/13/2023 04:49:23 PM


Document Has Been Signed on 03/13/2023 04:49 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 #4FACILITY NUMBER:
435202403
ADMINISTRATOR:DIOSDADO S. ARINESFACILITY TYPE:
740
ADDRESS:243 MARTINVALE LN.TELEPHONE:
(408) 622-6293
CITY:SAN JOSESTATE: CAZIP CODE:
95119
CAPACITY:6CENSUS: 6DATE:
03/13/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:DIOSDADO S. ARINESTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to open an initial complaint investigation. A case management – deficiencies visit was conducted due to a violation observed during visit. LPA met with Administrator, Diosdado Arines and Licensee, Hassan Ebadat .

During visit, LPA toured the facility with staff (S1) to include the living room, kitchen, resident rooms, bathroom, garage, and backyard.

LPA observed 2 built-in bedrooms inside the garage that houses 3 live-in staff (S1 – S3). The built-in bedroom walls are touching the ceiling. The Licensees states the built-in bedrooms were completed last week and the facility did not have the built-in bedrooms inspected in the garage nor did they obtain a permit or fire clearance.

Based on record review, the facility sketch did not show the built-in bedrooms in the garage nor did the facility obtained a permit.

The Licensee was informed that a persons cannot be sleeping inside the garage unless approved by the Department and/or fire department. The Licensee states they will be moving the staff outside of the garage and states a plan to re-arrange the living arrangement inside the facility.

A deficiency is being cited per California Code of Regulations, Title 22. See LIC809-D.

This report was reviewed with Administrator, Diosdado Arines and Licensee, Hassan Ebadat and a copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 03/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2023
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 03/13/2023 04:49 PM - It Cannot Be Edited

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 #4
FACILITY NUMBER: 435202403

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/14/2023
Section Cited

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(a) Prior to construction or alterations, all facilities shall obtain a building permit. This requirement is not met as evidenced by:
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Licensee will ensure to move all the staff out of the garage today. Licensee will obtain an approved fire clearance prior to staff living in the garage. Licensee will submit an updated facility sketch and request for a fire clearance to the Department to LPA Dolores via email by POC due date.
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Based on observation, interview, and record review the licensee built-in 2 bedrooms in the garage to house 3 live-in staff without obtaining a permit and approval which poses an immediate health, safety, and personal rights risk to persons in care.
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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: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 03/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2023
LIC809 (FAS) - (06/04)
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