435202866-8-18-2026-26-AS-MPAA-DX3PXG-20260818114215

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202866
Report Date: 08/17/2026
Date Signed: 08/18/2026 11:42:51 AM

Document Has Been Signed on 08/18/2026 11:42 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
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:	08/17/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:38 PM
MET WITH:	Shujen Collado - Administrator		TIME VISIT/ INSPECTION COMPLETED:	04:30 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	Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced Annual Required Inspection and met with Administrator (ADM) Shujen Collado. LPA stated the purpose of the visit. The facility is licensed to serve adults 60 years of age and older. The facility is approved to serve up to six (6) ambulatory residents, of whom two (2) may be non-ambulatory. At the time of the visit, LPA observed staff present at the facility. LPA observed one (1) resident in the living room and one (1) resident resting in a bedroom. Three (3) of five (5) residents were not present at the facility. Staff 1 (S1) stated the facility currently has six (6) residents; however, one (1) resident was admitted to the hospital at the time of the visit. LPA toured the facility with S1, including common areas, resident bedrooms, bathrooms, kitchen, driveway, outdoor areas, and storage areas. The indoor temperature measured 74 degrees Fahrenheit and was within regulatory range. LPA inspected the kitchen and food storage areas. Knives, cleaning supplies, and chemicals were secured and inaccessible to residents. The facility maintained at least a two-day supply of perishable food and a seven-day supply of nonperishable food. Kitchen hot water temperature measured 114.4 degrees Fahrenheit. Bathroom hot water temperatures ranged from 114 degrees Fahrenheit to 114.2 degrees Fahrenheit and were within regulatory range. page 1 of 2

Romeo Manzano
Maria Partoza
	DATE: 08/17/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2026

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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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)

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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 #6	FACILITY NUMBER: 435202866
	VISIT DATE: 08/17/2026

NARRATIVE

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Bathrooms were equipped with grab bars and non-skid mats. Resident bedrooms contained required furnishings and storage space for residents' personal belongings. Medications were centrally stored, locked, and inaccessible to residents. The facility maintained a first aid kit with required supplies.

LPA inspected the outdoor areas. Laundry appliances were operational, and cleaning supplies were secured and inaccessible to residents. Hallways and passageways are free from obstructions and tripping hazard.

During today's visit, LPA toured a newly converted two bedroom and bathroom area formerly identified as an office on the facility sketch. S1 stated the area is designated for staff use only. Records reviewed indicated fire clearance for the area was approved on 03/18/2026.

During the physical plant inspection, LPA observed Resident Room #1 contained two beds. One bed was positioned in front of and obstructed access to a sliding door. The sliding door leads to an exterior ramp, which leads toward the facility gate and exit to the street.

LPA reviewed Resident 1's (R1) records. R1's Physician's Report (LIC 602) documented that R1 is non-ambulatory, bedridden, requires continuous bed care, and requires staff assistance with repositioning while in bed. LPA reviewed the facility's current fire clearance and determined the facility is not approved to retain bedridden residents.

The facility is equipped with a fire alarm system, smoke detectors, carbon monoxide detectors, and one (1) fire extinguisher. LPA observed the fire extinguisher pressure gauge within the operable range, and the safety pin and tamper seal were intact. Fire and life-safety equipment observed during the visit was operational.

The facility conducts fire and earthquake drills quarterly for each shift. Records reviewed documented a disaster drill conducted on 02/06/2026.

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NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/17/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2026

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 #6	FACILITY NUMBER: 435202866
	VISIT DATE: 08/17/2026

NARRATIVE

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LPA reviewed three (3) of six (6) resident records and three (3) staff records. Records reviewed included admission agreements, physician reports, appraisals/needs and services plans, health screenings, staff training records, criminal record clearances, and personal and incidental records. Staff records reviewed contained required criminal record clearances. During record review, LPA identified additional items requiring follow-up and further review. Medication records were not reviewed during today's visit.

During today's visit, LPA identified deficiencies based on California Code of Regulations CCR Title 22;

87202(a)(2) – Fire Clearance Retaining R1, who is documented as bedridden, without an approved bedridden fire clearance.

87307(d)(2) – Personal Accommodations and Services Bed obstructing access to the sliding door/egress route leading to the ramp, gate, and street.

87303(a) – Maintenance and Operation Broken/damaged screen on the sliding door; facility component not maintained in good repair.

87463 – Reappraisals - R3’s appraisal/needs and services plan was last completed on 01/22/2024 and was not updated within the required time frame.

87506(a) – Resident Records R3’s record did not contain the signed consent/release-of-information documentation at the time of record review (technical violation)

Due to time constraint, LPA will return at a future date to continue the inspection, complete the remaining record and medication review, and issue citations for deficiencies identified during today's visit. Additional deficiencies may be cited, if identified during the continuation visit. Citations will be issued at the follow-up visit, as applicable.

An exit interview was conducted with ADM, and a copy of this report was provided.

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END OF REPORT

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/17/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2026

LIC809 (FAS) - (06/04)

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