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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202719
Report Date: 07/27/2024
Date Signed: 07/27/2024 01:03:04 PM

Document Has Been Signed on 07/27/2024 01:03 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 #2FACILITY NUMBER:
435202719
ADMINISTRATOR/
DIRECTOR:		SHU JEN COLLADOFACILITY TYPE:
735
ADDRESS:5686 TONOPAH DRTELEPHONE:
(408) 224-8258
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 6CENSUS: 5DATE:
07/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Administrator Shu Jen ColladoTIME VISIT/
INSPECTION COMPLETED:
01:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator Shu Jen Collado. During the visit, LPA observed 5 residents and 1 staff.

As LPA entered the home, LPA observed Direct Care Staff Schedule, dated July 22, 2024-July 28, 2024. The form states at 10:00am, 4 staff are scheduled. ADM stated she is the only staff member at the facility. ADM stated the facility currently has 5 residents inside the home. ADM stated one of the care givers went to the other care home. ADM stated the other staff member was on their way to the facility. Staff S2 arrived to the facility at 10:40am. Facility Licensee arrived at 10:55am.

LPA toured the facility inside out with ADM which included the Living room, kitchen, dining room, 2 restrooms and 3 residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected. There was no obstruction to block the walkways. LPA toured the garage. The garage was being used as a storage area.

LPA toured the outside of the facility. LPA observed the window screen for the kitchen had a layer of dust. LPA observed the exit to the back yard (Near the dining room and family room) is missing its sliding screen door. (Photographs were taken.)

Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 75 degrees F, and hot water temperature was measured at 116 degrees F in both resident bathrooms.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 07/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
Document Has Been Signed on 07/27/2024 01:03 PM - It Cannot Be Edited


Created By: Manuel Monter On 07/27/2024 at 12:25 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: EBADAT RESIDENTIAL CARE HOME #2
FACILITY NUMBER: 435202719

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
85065.5(a)(1)
Day Staff-Client Ratio
(1) For Regional Center clients, staffing shall be maintained as specified by the Regional Center but no less than one direct care staff to three such clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and observation, the licensee did not comply with the section cited above. Based on the direct care staff schedule, the facility was scheduled to have 4 staff at 10:00am. ADM stated she is the only staff member at the facility. ADM stated the facility currently has 5 residents inside the home. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/28/2024
Plan of Correction
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ADM stated she will send a written plan of action on how the facility will ensure staffing shall be maintained as specified by the Regional Center but no less than one direct care staff to three such clients. ADM stated she will send the written plan of action to LPA by POC date, July 28, 2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Romeo Manzano
LICENSING EVALUATOR NAME:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 07/27/2024 01:03 PM - It Cannot Be Edited


Created By: Manuel Monter On 07/27/2024 at 12:25 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: EBADAT RESIDENTIAL CARE HOME #2
FACILITY NUMBER: 435202719

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. The facility kitchen window screen contains dust. LPA observed the exit to the back yard (Near the dining room and family room) is missing its sliding screen door. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/02/2024
Plan of Correction
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ADM stated she will send a plan of action on how she will ensure all facility screens are in good repair and free of insects, dirt and other debris. ADM stated she will send LPA photo documentation showing the sliding screen door next to the family room and dinning room has been installed. ADM stated she will send the plan of correction by POC date, August 2, 2024.
Type B
Section Cited
HSC
1565(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 individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (interview & record review, the licensee did not comply with the section cited above. The facility's last drill was on June 20, 2021. LPA asked ADM if any drills had been conducted in 2024. ADM stated they have not conducted any drills in 2024. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/02/2024
Plan of Correction
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ADM stated she will conduct a fire drill and send documentation to LPA that a drill has taken place. ADM stated she will send the plan of correction by POC date, August 2, 2024.
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:Romeo Manzano
LICENSING EVALUATOR NAME:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2024


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 #2
FACILITY NUMBER: 435202719
VISIT DATE: 07/27/2024
NARRATIVE
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Fire extinguisher was serviced in April 15, 2024. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on June 20, 2021. LPA asked ADM if any drills had been conducted in 2024. ADM stated they have not conducted any drills in 2024.

LPA reviewed facility records for 3 staff and 3 residents. LPA reviewed 3 resident medications and centrally stored medication records. LPA reviewed 3 resident P&I records. LPA conducted interviews with 1 staff and 2 residents.

LPA requested ADM to send the following updated documents (if applicable) to LPA by August 2, 2024.
1.LIC 500, Personnel Summary
2.LIC 308, Designation of Administrative Responsibility
3.LIC400, Affidavit Regarding Client/Resident Cash Resources
4. Liability Insurance
5. LIC200, please update (i.e., new phone numbers etc), if necessary.
6. Qualifications of Administrator (Certificate)
7. Please review your facility program for updates (incorporating new laws and/or regulations)
8. Copy of surety bond

Deficiencies are being cited during today's visit. This report was reviewed with Administrator Shu Jen Collado and a copy of the signed report was provided. Appeal Rights were provided.

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END OF REPORT.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2024
LIC809 (FAS) - (06/04)
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