435202626-5-17-2024-26-AS-KHOS-D8AG89-20240819050645

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202626
Report Date: 05/17/2024
Date Signed: 05/17/2024 11:20:39 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/13/2024 and conducted by Evaluator Christine Dolores

COMPLAINT CONTROL NUMBER: 26-AS-20240513090627

FACILITY NAME:	EBADAT RESIDENTIAL CARE HOME # 5		FACILITY NUMBER:	435202626
ADMINISTRATOR:	CORONEL, AARON-DELL		FACILITY TYPE:	740
ADDRESS:	734 CHATSWORTH PL		TELEPHONE:	(408) 334-8995
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95128
CAPACITY:	6	CENSUS: 6	DATE:	05/17/2024
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Aaron-Dell Coronel		TIME COMPLETED:	11:25 AM

ALLEGATION(S):

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Staff are not properly trained to care and supervise resident with a restricted health condition

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to open the initial complaint investigation. LPA met with Administrator (ADM), Aaron-Dell Coronel.

On 05/13/2024, the Department received a complaint alleging that staff are not properly trained to care and supervise resident with a restricted health condition. On 05/17/2024, the initial complaint investigation was conducted.

The following documents were obtained to include resident (R1)’s physician’s report, functional capabilities, IPP, restricted health condition care plan, staff training, exception request, and medical records.

On 05/07/2024, resident (R1) was discharged from the hospital with a restricted health condition. PAGE 1 OF 2.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20240513090627

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/17/2024

NARRATIVE

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Based on interview, on 05/07/2024 around 5:00PM the ADM was notified of the restricted health condition when R1 was already in the ambulance en route back to the facility from the hospital.

The ADM immediately contacted a home health agency to provide training to staff. Based on record review the training with the home health agency was completed on the same day.

On 05/08/2024 around 4:00PM – 5:00PM, R1’s responsible party through San Andreas Regional Center (SARC) was contacted; however, ADM did not speak with SARC until 05/09/2024. On 05/09/2024, the facility was instructed to create an urgent restricted health condition care plan. Based on record review, on 05/09/2024 the restricted health condition care plan was completed by the facility nurse consultant and pending approval by SARC. On 05/15/2023, the facility was pending additional documentation to SARC. On 05/16/2024, the additional documentation was submitted and the restricted health condition care plan was approved.

As of today’s visit, of 05/17/2024, the facility’s nurse consultant has not yet completed the staff training on R1’s restricted health condition care plan. ADM states the plan for the facility’s nurse consultant to complete the training, ASAP.

The Department has investigated the above allegation. Based on interview, record review, and observation the preponderance of evidence standard has been met, therefore, the above allegation is substantiated. A deficiency was cited per California Code of Regulations, Title 22. SEE LIC9099-D. Advisory note provided.

This report was reviewed with Administrator, Aaron-Dell Coronel and a copy of the report and appeal rights were provided.

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SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20240513090627

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/17/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/18/2024 Section Cited CCR 87613(a)(1)	1 2 3 4 5 6 7	(a) Prior to admission of a resident with a restricted health condition, the licensee shall: (1) Communicate with all other persons who provide care to that resident to ensure consistency of care for the condition. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee plans to submit R1's restricted health condition care plan training to LPA by POC due date. Licensee will also submit a statement of understanding of the section cited. POC will be sent to LPA Dolores via email by POC due date .
	8 9 10 11 12 13 14	Based on interview, record review, and observation the licensee did not ensure to immediately communicate with the appropriate agencies responsible for R1’s care to ensure a restricted health condition care plan was in place upon being notified of R1's restricted health condition which poses an immediate health, safety and personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 05/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024

LIC9099 (FAS) - (06/04)

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