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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202866
Report Date: 06/04/2025
Date Signed: 06/04/2025 03:50:26 PM

Unsubstantiated


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
02/28/2025 and conducted by Evaluator Marcella Tarin
COMPLAINT CONTROL NUMBER: 26-AS-20250228175119
FACILITY NAME:EBADAT RESIDENTIAL CARE HOME #6FACILITY NUMBER:
435202866
ADMINISTRATOR:EBADAT, HASSANFACILITY TYPE:
740
ADDRESS:697 GLENBURRY WAYTELEPHONE:
(408) 334-8995
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY:6CENSUS: 6DATE:
06/04/2025
UNANNOUNCEDTIME BEGAN:
03:25 PM
MET WITH:Administrator (ADM) Shujen Collado TIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Facility did not ensure assistance is provided to residents in meeting or arranging his/her medical and health needs.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced visit to deliver the findings of the complaint investigation. LPA met with Administrator (ADM) Shujen Collado and stated the purpose of the visit.

On 2/28/2025, the Department received a complaint with the above allegation.

On 3/5/2025, the Department conducted an investigation and interviewed Witness 1 (W1). W1 stated that the physician's staff called facility staff (S1) 4 to 5 times and S1 made excuses or ignored the calls. S1 canceled an important follow up appointment for R1. W1 stated that S1 told the doctor staff that R1 is fine and does not need a follow up appointment. W1 stated that S1 asked for another date for R1 to be seen and S1 was told that the next available appointment will be end of April or early May. W1 stated that the physician's staff explained the need for R1 to be seen by the doctor to S1.
Page 1 of 2 see LIC 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jin Jackie
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 26-AS-20250228175119
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 #6
FACILITY NUMBER: 435202866
VISIT DATE: 06/04/2025
NARRATIVE
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On 3/5/2025 and 4/4/2025, S1 was interviewed and stated the following, office staff called informing him/her of R1s upcoming appointment in 5 days after R1's visit with the specialist. The doctor's office staff asked how R1 is doing, which S1 responded by saying R1 looks fine and does not have any problem. S1 stated on the day of the appointment R1 had a tantrum and refused to go to his/her appointment and S1 canceled the appointment because R1 refused. S1 stated he/she asked for another appointment but was told that the date and time given was the earliest schedule available, otherwise the next appointment will be end of April or early May.

On 4/4/2025 LPA interviewed 2 staff (S1 and S2). Based on interview, 2 Out of 2 staff stated that no residents throws a tantrum and no resident refuses to go to a medical appointment. 2 Out of 2 staff stated that R1 does not have tantrums. 2 Out of 2 staff stated that the residents are always on time with their medical appointment. 2 Out of 2 staff stated that resident 2 (R2) has more behavioral issues than any of the residents in the facility.

Based on document review of 3 out of 3 residents file; the facility kept a record for 3 out of 3 resident's health care appointments. R1 kept his/her appointment for August 2024 and February of 2025. R1s health care appointments were monitored and recorded by the facility, however, some appointments were not recorded.

Based on this interview and documents review, although the allegation may have happened or is valid there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

No deficiency is cited during today's visit based on California Code of Regulations (CCR) Title 22.
An exit interview was conducted with Administrator (ADM) Shujen Collado . A copy of the report was provided.


Page 2 of 2
End of report
SUPERVISORS NAME: Jin Jackie
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2