435202626-9-30-2025-26-AS-MPAA-DLZV5Y-20250930160842

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202626
Report Date: 09/30/2025
Date Signed: 09/30/2025 04:08:55 PM

Document Has Been Signed on 09/30/2025 04:08 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/ DIRECTOR:	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:	09/30/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:00 PM
MET WITH:	Aaron-Dell Coronel-Administrator		TIME VISIT/ INSPECTION COMPLETED:	05:00 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) Maria (Mita) Partoza conducted an unannounced required 1 year visit and met with administrator (ADM) Aaron-Dell Coronel. LPA stated the purpose of the visit. The facility is licensed to serve adults 18 to 59 years old who are developmentally challenged, ambulatory and non-ambulatory. At 1:10 p.m LPA inspected the facility inside and outside and was accompanied by ADM. LPA observed that all exit doors, walkways, ramps and hallways were free from obstruction. The backyard was well maintained an no debris were observed. LPA inspected the kitchen, dining, living room, 4 resident bedrooms, 2 bathrooms, laundry room and garage. LPA observed no obstruction on the hallways, night lights were available to illuminate the hallways. 2 Out of the 4 bedroom are shared and 2 Out of the 4 are not shared. The bathrooms are equipped with grab bars and non-skid mats. Each bedroom bedding, are sanitary and organized, has sufficient storage to store resident's personal belongings and functioning lights. 2 of the resident beds observed with half bed rails that were prescribed by their primary care physician for the safety of the resident. The facility has a room temperature of 70 degree F, water temperature measured at 112.4 to 113.4 degree F. The refrigerator temperature is at 37 degree F and freezer temperature is at -3 degree F. page 1 of 2

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2025

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: 09/30/2025

NARRATIVE

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In the kitchen, LPA observed that sharps, medications, are not accessible to residents in care. LPA observed 2 days of perishable items in 7 days of non-perishable items. LPA did not observed any food on the counters that were exposed and no open cartons of food stored.

LPA observed that cleaning supplies, and laundry supply are not accessible to residents in care and stored separately from the food storage.

LPAs observed first aid kit was complete. Facility has flashlights and batteries. LPA observed the fire extinguisher was last serviced on 08/11/2025. Fire extinguisher was inspected by the vendor on 08/11/2025 and the fire alarm is connected to the fire department. Smoke and carbon monoxide - are in good working condition. The facility disaster preparedness training was conducted on July 29,2025, Fire drill was conducted on August 18, 2025 and earthquake drill was conducted on July 14, 2025.

3 resident records were reviewed and verified to be complete and up to date. LPA reviewed the admission agreement, physician's report, TB result, appraisal needs and services plan and individual program plan, identification and emergency contact information, safeguard of personal properties and valuables, personal rights, and consent forms the centrally stored medications and destruction record and personal and incidental allowance.

3 staff record was reviewed and was verified to be complete and up to date such as but not limited to 1st aid/CPR training, personal rights of the residents, health screening, medical training and Statement Acknowledging Requirement to report Suspected Abuse of Dependent Adults and Elders (SOC341A), fingerprint and background clearance.

LPA requested the following documents from ADM - LIC500 (Personnel Report) Liability Insurance, designation of responsibility (LIC308) and Lease Agreement.

No deficiencies were cited during today's visit based on California Code of Regulations (CCR) Title 22. An exit interview was conducted with administrator, Aaron Dell Coronel and a copy of this report were provided.

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end of report

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2025

LIC809 (FAS) - (06/04)

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