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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202945
Report Date: 09/20/2024
Date Signed: 09/21/2024 03:42:27 PM

Document Has Been Signed on 09/21/2024 03:42 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 # 7FACILITY NUMBER:
435202945
ADMINISTRATOR/
DIRECTOR:		EBADAT, HASSANFACILITY TYPE:
735
ADDRESS:5232 CAMDEN AVETELEPHONE:
(408) 334-8995
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY: 6CENSUS: 0DATE:
09/20/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Aarondell CoronelTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Steve Chang conducted an pre-licensing inspection visit and met with staff Aarondell Coronel (S1).

LPA toured the facility inside and out with S1. Living room, dining room, kitchen, 6 bedrooms, 3 restrooms, and laundry area were inspected.

The facility Applies for SARC vendorization.

Room temperature was observed at 71 degree F. Hot water temperature was observed at 106 degree F. Refrigerator temperature was observed at 37 degree F. Freezer temperature was observed at 0 degree F. all the bedrooms were observed with window screens.

Fire extinguisher was serviced on 06/11/2024. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors was tested by S1, and were working fine. Medications closet was observed locked. Knives closet and detergent closet were observed locked.

Night lights, first aid box, and flash lights were observed in the facility.

LPA toured the backyard and frontyard, no obstruction was observed to block the walkway.

Component III was conducted with S1.

No deficiency/citation noted today. Exit interview was conducted with S1. The report was provided to S1 for signature. A copy of the report was issued to S1.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2024
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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