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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202403
Report Date: 03/06/2024
Date Signed: 03/06/2024 03:22:47 PM


Document Has Been Signed on 03/06/2024 03:22 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 #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: 5DATE:
03/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Hassan EbadatTIME COMPLETED:
12:39 PM
NARRATIVE
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Licensing Program Analyst (LPA) Steve Chang arrived unannounced to conduct the facility's annual inspection. LPA met with Licensee, Hassan Ebadat (LCN).

LPA toured the facility inside and out with LCN. 2 staff and 2 residents were observed in the facility. 3 residents went to day program. Facility license, Administrator Certificate and Personal Rights posters were observed in the facility.

LPA reviewed 3 resident files and 3 staff files.

LPA toured the facility to include the living room, dining room, kitchen, resident bedrooms, bathroom, garage, and backyard. All fire exit routes were free and clear of obstruction. All staff present are fingerprint cleared and associated to the facility.

Facility temperature maintained at 71 degrees Fahrenheit. Hot water temperature maintained at 106 degrees Fahrenheit. Facility's fire extinguisher last serviced on 04/6/2023. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Medication closet Knives closet, and cleaning product closet were observed locked. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Fire alarm and smoke detectors were tested by ADM. The fire alarm and smoke detectors were working fine. Flash lights and first aid box were observed in the facility.

The last time the facility conducted the emergency and fire drill was 2/20/2024.

Deficiencies noted today. See 809-D. Exit interview was conducted with LCN. The report was provided to LCN for signature. A copy of the report was provided to LCN.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2024
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 2


Document Has Been Signed on 03/06/2024 03:22 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
CCLD Regional Office, 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: 03/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to:

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 2 out of 3 residents' Appraisal Needs and Service plan were not signed by the facility and the facility staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/13/2024
Plan of Correction
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Licensee stated to submit a plan of correction by the POC due date to have resident family and the facility staff to sign.
Type B
Section Cited
CCR
87507(c)
Admission Agreements
(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above.

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 2 out of 3 residents' admission agreements were not signed by the family and the facility staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/13/2024
Plan of Correction
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Licensee stated to submit a plan of correction by the POC due date to have resident family and the facility staff to sign the admission agreements.
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 ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2