435202866-8-23-2026-26-AS-MPAA-DX96Z7-20260823211441

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202866
Report Date: 08/20/2026
Date Signed: 08/23/2026 09:16:42 PM

Document Has Been Signed on 08/23/2026 09:16 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 #6		FACILITY NUMBER:	435202866
ADMINISTRATOR/ DIRECTOR:	COLLADO, SHUJEN		FACILITY TYPE:	740
ADDRESS:	697 GLENBURRY WAY		TELEPHONE:	(408) 334-8995
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95123
CAPACITY: 6		CENSUS: 6	DATE:	08/20/2026
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:05 AM
MET WITH:	Shujen Collado - Administrator		TIME VISIT/ INSPECTION COMPLETED:	01:30 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	On 08/20/2026, Licensing Program Analyst (LPA) conducted an unannounced continuation of the Annual Required Inspection initiated on 08/17/2026. LPA met with the Licensee Corey Ebadat and Administrator Shujen Collado and stated the purpose of the visit. During the initial inspection, LPA toured the facility, reviewed three (3) of six (6) resident records and three (3) staff records, and identified items requiring additional review. LPA returned on 08/20/2026 (today's date) to continue the inspection and address deficiencies identified during the initial visit. During today's visit, LPA met with the Licensee and Administrator to discuss Resident 1's (R1) care needs and placement at the facility. The Licensee and Administrator stated they were not aware that an appropriate fire clearance was required to retain a bedridden resident and believed the information provided at the time of placement was sufficient. LPA reviewed R1's records with the Licensee and Administrator and discussed the level of assistance documented prior to placement. Records reviewed documented that R1 required extensive assistance with activities of daily living and two-person assistance with transfers prior to placement. The Licensee and Administrator acknowledged that R1 currently requires total assistance with care and stated that facility staff take turns providing R1's care. page 1 of 2

Romeo Manzano
Maria Partoza
	DATE: 08/20/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2026

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 6

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)

Page: 2 of 6

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 #6	FACILITY NUMBER: 435202866
	VISIT DATE: 08/20/2026

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
26
27
28
29
30
31
32

The Licensee and Administrator stated that R1 was one of the earlier residents referred to the facility and that the facility had fewer residents at the time of R1's admission. Staff adjusted their routines to accommodate R1's care needs.

LPA advised the Licensee and Administrator that the facility remains responsible for reviewing a prospective resident's care needs and determining whether those needs are consistent with the facility's approved fire clearance and scope of care prior to admission and throughout the resident's stay.

Review of the facility's fire clearance determined that the facility is not approved to retain a bedridden resident. The Licensee stated they are currently working with R1's service coordinator to request reassessment and relocation to a facility that can meet R1's current care needs.

During the initial inspection, LPA also observed a bed positioned in front of a sliding door in a resident bedroom, obstructing access to the passageway leading to the exterior ramp. LPA observed that the sliding door screen was damaged. Record review determined that R3's most recent appraisal available for review was dated 01/22/2024.

Technical Assistance was provided regarding CCR Title 22, Section 87506(a), Resident Records. LPA advised the Licensee and Administrator to ensure resident records are complete, current, and contain applicable signatures and documentation.

Deficiencies are cited pursuant to California Code of Regulations, Title 22, and are documented on the attached LIC 809-D.

The Licensee and Administrator left the facility prior to completion of the visit due to a prior commitment. Prior to leaving, the Licensee and Administrator discussed with LPA their plans to correct the identified deficiencies. The Licensee and Administrator authorized Lead Staff Edna Danga to review and sign the report on their behalf.

An exit interview was conducted with Lead Staff Emma Danga. This report, LIC 809-D, Plan of Correction requirements, and appeal rights were reviewed, and a copy of the report was provided.

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/20/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2026

LIC809 (FAS) - (06/04)

Page: 3 of 6

Document Has Been Signed on 08/23/2026 09:16 PM - It Cannot Be Edited

Created By: Maria Partoza On 08/20/2026 at 12:12 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 #6	FACILITY NUMBER: 435202866
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/20/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)(2)

87202(a)(2) – Fire Clearance: “All facilities shall maintain a fire clearance approved by the...fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance... (2) Bedridden persons.” This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review conducted on 08/17/2026 and 08/20/2026, the licensee did not comply with the section cited above in 1 out of 6 persons, R1, who was retained as a bedridden resident without the appropriate fire clearance, which poses an immediate health and safety risk to persons in care.
	POC Due Date: 08/21/2026
	Plan of Correction
1 2 3 4	Licensee stated they will request reassessment and relocation of R1 through the service coordinator. If R1 remains, Licensee will pursue the appropriate fire clearance. A written plan of correcntion (POC) and memorandum of understanding (MOU) will be submitted to CCL on or before close of busines of 08/21/2026.

Type A

Section Cited

CCR

87307(d)(6)

87307– Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities: (6)All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation conducted on 08/17/2026, the licensee did not comply with the section cited above in 1 out of 1 observed passageway, where a bed obstructed access to a sliding door leading to an exterior ramp, which poses an immediate health and safety risk to persons in care.
	POC Due Date: 08/21/2026
	Plan of Correction
1 2 3 4	Licensee stated that he/she will reposition the bed to keep the passageway unobstructed and submit proof of correction to CCL on or before end of day of 08/21/2026.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:

	Maria Partoza
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/20/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2026

LIC809 (FAS) - (06/04)

Page: 4 of 6

Document Has Been Signed on 08/23/2026 09:16 PM - It Cannot Be Edited

Created By: Maria Partoza On 08/20/2026 at 12:43 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 #6	FACILITY NUMBER: 435202866
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/20/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(c)

87303 Maintenance and Operation (c) All window screens shall be clean and maintained in good repair. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation conducted on 08/17/2026, the licensee did not comply with the section cited above in 1 out of 1 observed window screen, which was damaged and not maintained in good repair, which poses an immediate health and safety risk to persons in care.
	POC Due Date: 08/21/2026
	Plan of Correction
1 2 3 4	Licensee stated that he/she will repair or replace the damaged screen and submit photographic proof to CCL on or before the end of day of 08/21/2026.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:

	Maria Partoza
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/20/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2026

LIC809 (FAS) - (06/04)

Page: 5 of 6

Document Has Been Signed on 08/23/2026 09:16 PM - It Cannot Be Edited

Created By: Maria Partoza On 08/20/2026 at 12:48 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 #6	FACILITY NUMBER: 435202866
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/20/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87463(a)

87463 Reappraisal (a) The pre-admission appraisal...shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first...and to keep the appraisal accurate. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review conducted on 08/17/2026, the licensee did not comply with the section cited above in 1 out of 3 resident records reviewed, R3, whose most recent appraisal was dated 01/22/2024 and no current reappraisal was available for review, which poses a potential health and safety risk to persons in care.
	POC Due Date: 09/03/2026
	Plan of Correction
1 2 3 4	Licensee will complete R3’s reappraisal and submit proof of completion to CCL on or before the POC due date of 09/03/2026.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:

	Maria Partoza
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/20/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2026

LIC809 (FAS) - (06/04)

Page: 6 of 6