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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202719
Report Date: 07/28/2022
Date Signed: 07/28/2022 02:31:13 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 07/28/2022 02:31 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
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:
07/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Carolina Manliclic, TIME COMPLETED:
02:10 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with House Manager (HM) Carolina Manliclic. Upon arrival, Staff Jennifer Collado (S1) took LPA body temperature, and checked LPA in the visitor log book.

LPA toured the facility inside out with HM. COVID posters were observed at main entrance and in the facility. Screening station with masks, hand sanitizer, thermometer and visitor log book was observed at the main entrance. Family room, Living room, kitchen, dinning room and two restrooms were inspected. All trash cans were observed with covers. Paper towels were observed with holders. Three shared resident bedrooms, and laundry room were inspected. One staff live-in room was observed in facility. Cloth towels were observed in kitchen and restrooms. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Medication closet, knives closet, and cleaning product closet were observed locked. Room temperature was at 74 degree F, and hot water temperature was at 110 degree F in facility. Two residents and 2 staff were observed in facility.

Fire extinguisher was serviced on 04/18/2022. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors was tested by HM, and were working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways.

HM stated all the residents and staff are fully vaccinated and done with booster. No deficiency or citation were noted today. Exit interview was conducted with HM. This report was provided to HM for signature.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2022
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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