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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202719
Report Date: 03/18/2022
Date Signed: 03/21/2022 10:48:05 AM

Document Has Been Signed on 03/21/2022 10:48 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:EBADAT RESIDENTIAL CARE HOME #2FACILITY NUMBER:
435202719
ADMINISTRATOR:EBADAT, HASSANFACILITY TYPE:
735
ADDRESS:5686 TONOPAH DRTELEPHONE:
(408) 224-8258
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 6CENSUS: 6DATE:
03/18/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Shu-Jen ColladoTIME COMPLETED:
02:40 PM
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Licensing Program Analyst (LPA) Christine Dolores conducted a scheduled technical assistance visit and met with Administrator Shu-Jen Collado. During visit, LPA conducted a zoom tour of the facility with Licensing Program Manager (LPM) Sarah Yip. The purpose of the visit was to provide technical assistance to prevent and mitigate the spread of COVID-19 in the facility. The Administrator reports zero COVID-19 residents and staff. The last COVID-19 resident was cleared off isolation on 03/13/2022.

During today's tele-visit, the following recommendations were made to the facility by LPA and LPM:

1. Create a screening log for staff
2. Provide N95 fit-testing to facility staff
3. Place a hand-washing sign in all bathrooms and throughout facility
4. Remove common cloth towels in the kitchen area
5. Train staff on infection control to include donning and doffing PPE
6. Place a PPE cart outside the isolation room, when isolation room is in use
7. Place a trash-can with lid outside the isolation room for PPE disposal, when isolation room is in use
8. Place proper signs outside the isolation room, when in use, to include an isolation sign and donning and doffing PPE

LPA will provide facility with COVID-19 resources.

No deficiencies were cited as per California Code of Regulations, Title 22. This report was reviewed via telephone with Administrator Shu-Jen Collado and a copy of this report was emailed for signature.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/18/2022
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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