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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202626
Report Date: 05/31/2023
Date Signed: 05/31/2023 01:03:17 PM

Document Has Been Signed on 05/31/2023 01:03 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:COLLADO, SHU-JENFACILITY TYPE:
740
ADDRESS:734 CHATSWORTH PLTELEPHONE:
(408) 334-8995
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY: 6CENSUS: 3DATE:
05/31/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Shu-Jen ColladoTIME COMPLETED:
01:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management - incident visit. LPA explained the purpose of the visit and met with Administrator (ADM), Shu-Jen Collado and Licensee, Corey Ebadat.

During visit, LPA toured the facility with staff to include the garage, resident rooms, bathrooms, living room, kitchen, dining room, and backyard. 3 out of 5 residents observed in the facility. 2 out of 5 residents were stated attending the day program.

From 05/23/2023 - 05/26/2023 the Department received several incident reports and SOC341's from the resident (R1)'s day program alleging abuse from the residential facility staff members. It was noted that there was no indication of physical pain or visible marking in the body part areas that were alleged hurt. During visit, LPA interviewed 4 staff members. 4 out of 4 staff members denied the allegation. Staff stated R1 has history of cursing staff and other residents and creating false stories.

On 05/23/2023, the ADM received an email from R1's day program regarding the allegations. The ADM responded to R1's day program denying the allegation. ADM informed the day program to review R1's Individual Program Plan (IPP) as the behavior of alleging abuse is part of R1's baseline. ADM stated to have spoken to the facility staff members and R1 regarding the allegation. ADM states all parties including R1 denied the allegation of abuse. A body check was not conducted because ADM states they knew the abuse was not happening as this was part of R1's behavior. ADM advised the facility staff to document the incidents going forward. ADM plans to inform the regional center and consult with R1's behaviorist to create a behavior plan to minimize the allegations. ADM already contracted R1's psychiatrist regarding the behavior. SEE LIC809-C.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2023
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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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: 05/31/2023
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Based on record review, R1 has moved from another care home due to alleged abuse incident by a peer. Record review states R1 has a behavior in telling false stories as a means of getting attention.

LPA obtained R1's IPP, physician's report, and preplacement appraisal information.

During visit, LPA entered the garage with staff. LPA observed a staff (S1) sleeping in the garage. ADM stated that S1 lives in the facility. Based on review of the facility sketch, the garage is not approved to be a bedroom. At 11:35am, S1 left the facility. Based on review of the facility's personnel summary, S1 was not associated to the facility roster. LPA reviewed S1's personnel file and observed S1's LIC9182 that was signed by ADM. ADM stated to have faxed the form to the Department on the day S1 was hired 2021. Licensee filled out another LIC9182 and emailed the form to the Department during visit. Based on record review, S1 is fingerprint cleared.

A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D. A technical violation was also provided. This report was reviewed with Administrator, Shu-Jen Collado and a copy of the report and appeal rights was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/31/2023 01:03 PM - It Cannot Be Edited


Created By: Christine Dolores On 05/31/2023 at 12:39 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: 05/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/01/2023
Section Cited
CCR
87307(a)

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(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: This requirement was not met as evidenced by:
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Licensee will advise the staff to sleep in another location and to remove all S1's personal belongings from the garage. Licensee will submit a statement of understanding to LPA Dolores via email by POC due date.
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Based on interview, observation, and record review the garage is not approved to be a bedroom when LPA observed staff (S1) sleeping in the garage 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 Yip
LICENSING EVALUATOR NAME:Christine Dolores
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2023


LIC809 (FAS) - (06/04)
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