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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202626
Report Date: 04/23/2025
Date Signed: 04/23/2025 07:25:42 PM

Document Has Been Signed on 04/23/2025 07:25 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 # 5FACILITY NUMBER:
435202626
ADMINISTRATOR/
DIRECTOR:		CORONEL, AARON-DELLFACILITY TYPE:
740
ADDRESS:734 CHATSWORTH PLTELEPHONE:
(408) 334-8995
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY: 6CENSUS: 6DATE:
04/23/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:Aaron-Dell CoronelTIME VISIT/
INSPECTION COMPLETED:
07:45 PM
NARRATIVE
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On 4/23/2025 LIcensing Program Analyst (LPA) Santino Fortes and Licensing Program Manager (LPM) Romeo Manzano made an unannounced visit to open a Personal rights complaint with ADM Aaron Coronel. During visit there were 5 staff and 6 residents observed.

During inspection visit, LPA and LPM arrived at the facility at 8:15am and met with 3 staff (S1-S3) in the dining/kitchen area. Five residents (R1-R5) were observed in the living room watching TV with Staff(S4). Staff stated breakfast service had just finished. LPA/LPM met with R6 at approximately 9am.

While LPA and LPM were in the kitchen/dining area, deficiencies were observed and being cited during today's visit, see LIC809-D. The following deficiencies were observed as follows: Resident restrained in wheelchair by a strap.

Medications are found accessible in a brown observed on top of an office table (against the wall on the left facing the street) in the main dining room accessible to residents in care. Staff S1-S3 stated that it belongs to 4 residents, R1 to R4. Staff stated that the medications were received last week and have not been logged to the Centrally Stored Medication form for May 2025. Staff were aware that medication has to be locked but when asked why medications were on top of the table unlocked, they were not able to provide an answer.
Staff were not administering medication during LPA/LPMs arrival or visit at the facility. LPA/LPM observed that the centrally stored medication cabinet next to the coffee machine/stove was unlocked. Staff/ADM agreed that medication cabinet must be locked at all times. LPA/LPM also provided guidance of the importance of keeping medication inaccessible residents. LPM provided guidance Title 22, Code Section 80075
Continuation on page, 2 of 2 (LIC809 C)
NAME OF LICENSING PROGRAM MANAGER: Jackie Jin
NAME OF LICENSING PROGRAM ANALYST: Santino Fortes
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/23/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: EBADAT RESIDENTIAL CARE HOME # 5
FACILITY NUMBER: 435202626
VISIT DATE: 04/23/2025
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A defrosted meat (pork chops) was observed sitting on top of the fire place brick left overnight since 7pm (4/22) per S1 to S3. Staff stated that it belongs to Staff (S5) The facility serves residents with developmental disabilities, 1 of which has a behavior of consuming anything that could potentially a choking hazard (R1) LPA/LPM also provided guidance in the importance of food handling and storage. LPM provided guidance Title 22, Code Section 80076.

During LPA/LPMs tour of the facility, R1 was observed in the living room area while seated on a wheelchair with a gait belt 'tied' around his/her waist. Staff and ADM state that R1 and R2 requires a seat belt to prevent them from sliding or falling. R1 and R2 does not have the ability and capacity to unlocked belt in case of an emergency. On the other hand, staff also stated that R2 also requires a seat belt when in wheelchair. LPA/LPM observed that R2 also utilized gait belt (blue in color). ADM stated gait belts were given to them by a physical therapist to help residents with ambulation but not to utilized as a seat belt. There are no physician's order on residents' file to utilize gait belt as a seat belt. LPM provided guidance Title 22, Code Section 80072

During interview with ADM regarding his work schedule, ADM stated that he visits or monitor facility five (5) days week from 1:00PM to 4:00PM. LPA/LPM also discussed about the importance of ADM's physical presence in the facility at least 20 hours a week during business hours, Monday to Friday, 8:00AM to 5PM. ADM also oversees another RCFE. LPA/LPM informed ADM to submit an updated LIC500 Personnel Summary to CCL by close of business on 4/25/25. ADM is also advised to call caseload LPA and/or Desk Duty Officer, if needed.

LPA/LPM also conducted a random review of residents' files. LPA/LPM also suggested that Appraisal Needs and Services need to be accurate in line with residents' IPP (Individual Program Plan) and kept up to date with resident behaviors not in the IPP. ADM agreed and understood.

LPA also discussed about CCLD's Technical Support Program (TSP). LPA informed ADM that TSP is voluntarily but it will beneficial for keep facility in compliance with Title 22 regulations and can be accessed on the CCLD website.

The following deficiencies were cited per CA Code of Regulations Title 22- refer LIC809-D. Appeal Rights information were provided and discussed with ADM
NAME OF LICENSING PROGRAM MANAGER: Jackie Jin
NAME OF LICENSING PROGRAM ANALYST: Santino Fortes
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 04/23/2025 07:25 PM - It Cannot Be Edited


Created By: Santino Fortes On 04/23/2025 at 03:49 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 # 5
FACILITY NUMBER: 435202626

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/23/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/24/2025
Section Cited
CCR
80072(a)(8)(C)

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Personal Rights (a)(8)(C):Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to...(8)Not to be placed in any restraining device.Postural supports may be used under the following conditions:(C) Postural supports
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Continuation:
R1 was observed seated in wheelchair tied with a gait belt and staff also stated they use gait belt for R2 which poses an immediate Health, Safety or Personal Rights risk to residents in care.
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shall be fastened or tied in a manner which permits quick release by the client. This requirement is not met as evidenced by: Based on inspection and observation,

(See continuation on next column, under Plan of Correction)
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ADM stated that he will provide a written plan of action by POC date 4/24/2025.
04/24/2025
Section Cited
CCR80076(13)(14)

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Food Services(13)(14): All persons engaged in food preparation and service shall observe personal hygiene and food services sanitation practices which protect the food from contamination. (14)All foods or beverages capable of supporting rapid and progressive
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Continuation:
defrost on the main dining table since the prior day, which poses an immediate Health, Safety or Personal Rights risk to residents in care.
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growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at 45 degrees F (7.2 degrees C) or less. This requirement is not met as evidenced by the observation of a package of raw meat left to
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ADM stated that he will provide food service training for food preparation and storage by POC date 4/24/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Jackie Jin
NAME OF LICENSING PROGRAM MANAGER:
Santino Fortes
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/23/2025 07:25 PM - It Cannot Be Edited


Created By: Santino Fortes On 04/23/2025 at 04:04 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 # 5
FACILITY NUMBER: 435202626

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/23/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/24/2025
Section Cited
CCR
80075(k)(1)

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Health Related Services(k)(1):The following requirements shall apply to medications which are centrally stored(1)Medication shall be kept in a safe and locked place that isnot accessible to persons other than employees responsible for the supervision of the centrally stored medication.
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Continuation:
to R1 to R4, which poses an immediate Health, Safety or Personal Rights risk to residents in care.
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This requirement is not met as evidenced by: Based on observation, medications are found accessible in a brown observed on top of an office table (against the wall on the left facing the street) in the main dining room which belongs. (See continuation on next column, under Plan of Correction)
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ADM stated that he will conduct a staff in service training on medication such as but not limited to storage and recording/logging in the centrally stored medicaiton log by POC date 4/24/25.

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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.
Jackie Jin
NAME OF LICENSING PROGRAM MANAGER:
Santino Fortes
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2025


LIC809 (FAS) - (06/04)
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