435202626-10-10-2023-26-AS-CDOS-CWH2CL-20231010171655

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202626
Report Date: 10/10/2023
Date Signed: 10/10/2023 05:17:03 PM

Document Has Been Signed on 10/10/2023 05:17 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 # 5		FACILITY NUMBER:	435202626
ADMINISTRATOR:	COLLADO, SHU-JEN		FACILITY TYPE:	740
ADDRESS:	734 CHATSWORTH PL		TELEPHONE:	(408) 334-8995
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95128
CAPACITY:	6	CENSUS: 6	DATE:	10/10/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:10 PM
MET WITH:	Aaron Coronel		TIME COMPLETED:	05:20 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's required 1 year inspection. LPA met with Administrator, Aaron Coronel. ADM started at the facility on 09/15/2023 and states he is still working on getting the facility back in compliance. During visit, LPA toured the facility with ADM to include the entrance, living room, resident bedrooms, staff bedroom, bathroom, kitchen, dining room, garage, and backyard. LPA observed there was a shed in the backyard. ADM did not have a key to the shed, therefore, LPA was unable to observe the inside of the shed. All fire exit routes are free and clear of obstruction. Facility temperature maintained at 72 degrees Fahrenheit. Fire extinguisher last services on 06/16/2023. Facility has at least one carbon monoxide detector located in the kitchen. Facility has a fire alarm pull system. Staff state they have not had an inspection from the fire department. Upon entrance, LPA observed a sign-in sheet, masks, hand sanitizers, and COVID-19 related posters. Additional signs were observed to include resident's personal rights, emergency disaster plan, infection control plan, emergency contact numbers, and activities calendar. LPA entered 3 resident bedrooms which contains 2 beds in each room. All resident bedrooms contained a bed, dressers, closet space, clean linens, and lighting. LPA observed residents R4 and R5's bed contains full length bed rails. The physician's order on file states an order for "side rails". ADM will confirm with the physician if full-length bed rails are needed. R4 - R5 are not receiving hospice care services. ADM was informed that an exception request is needed if R4 - R5 requires full-length bed rails. Bathrooms equipped with toilet paper, soap, and hand washing sign. Shower equipped with a shower chair, non-slip mat, and grab bars. Hot water temperature maintained at 126 degrees Fahrenheit. SEE LIC809-C.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

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: 10/10/2023

NARRATIVE

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Kitchen is supplied with 2 days worth of perishables and 7 days worth of non-perishable foods. Items in the refrigerator observed covered. Refrigerator temperature maintained at 38 degrees Fahrenheit. Freezer temperature maintained at -2 degrees Fahrenheit. Sharp objects, chemicals, and disinfectants observed locked. Medication cabinet located in the kitchen observed locked.

Facility has emergency telephone numbers posted at the front door. Each residents files contains an emergency information face sheet. LPA observed a complete first aid kit. Facility has emergency lighting and extra batteries. Staff has not conducted and documented quarterly emergency disaster drills. ADM was advised. PPE supplies observed to include gowns, shields, gloves, masks, disinfectants, and hand sanitizer.

LPA reviewed 4 resident records. 4 out of 4 resident records contained an admission agreement, physician's report, and TB result. R1 - R4's file contained an IPP. R1's IPP was last updated in 2020, R3's IPP was last updated in 2019, R4's IPP was last updated in 2021. ADM was advised. ADM is currently working on updating appraisal/needs and services plan. ADM states he can get them done by 10/20/2023. Residents who require a wheelchair does not have a weight record on file because the facility does not have the equipment to weigh residents in a wheelchair. Facility has collaborated with home health agency to obtain the weight record for residents in a wheelchair. 4 out of 4 residents centrally stored medication records and P&I money were reviewed. LPA observed each resident has a PRN medication log.

LPA reviewed 4 staff files. Current staff obtains a first aid certification, fingerprint clearance, health screening, and TB result. ADM obtains a current Administrator Certificate. Staff training records were reviewed. LPA did not observe staff were provided an annual 20 hours of training to include topics about dementia, postural supports, restricted health conditions, and hospice care.

The following documents were obtained: LIC-610E, LIC-9282, LIC-308, and liability insurance. ADM will email LPA the LIC-500 by 10/11/2023.

Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Administrator Aaron Coronel and a copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/10/2023 05:17 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 # 5	FACILITY NUMBER: 435202626
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review the licensee did not ensure staff were provided an additional 20 hours of annual training on the topics listed in this section which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/17/2023
	Plan of Correction
1 2 3 4	Licensee will enroll staff in training specific to the topics listed in this section. Licensee will submit a written plan to include the dates staff are enrolled and the instructor of the course to LPA Dolores via email by POC due date.

Type B

Section Cited

CCR

87463(c)

Reappraisals

(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review the licensee did not ensure resident's appraisal/needs and services plan and IPP was updated annually which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/24/2023
	Plan of Correction
1 2 3 4	Licensee will submit all residents updated appraisal/needs and services to include a date and signature to LPA Dolores via email by POC due date.

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	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 10/10/2023 05:17 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 # 5	FACILITY NUMBER: 435202626
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review the licensee did not ensure staff were provided a quarterly emergency drill which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/17/2023
	Plan of Correction
1 2 3 4	Licensee will submit the facility's emergency drill log to LPA Dolores via email by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

LIC809 (FAS) - (06/04)

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