Ebadat Residential Care Home #6

Type of visit: Case Management - Annual Continuation

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 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.the state’s words, verbatim · CDSS document, Aug 20, 2026

Type of visit: Required - 1 Year

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 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. page 2 of 3 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. page 3 of 3 END OF REPORTthe state’s words, verbatim · CDSS document, Aug 17, 2026

Type of visit: Case Management - Other

On March 24, 2026, Licensing Program Analyst Manuel Monter conducted an unannounced case management -other visit to follow up on the pending fire clearance. LPA met with Administrator Shujen Collado. On August 4, 2025, Licensing Program Analyst Manuel Monter conducted an unannounced annual inspection. During the inspection, LPA noted the facility’s office area and Sitting room did not match the approved fire clearance dated March 2, 2022. LPA spoke to Licensee (LN) Kourosh Ebadat. LN stated he just got a permit approval in May 2025, to convert the facility office to a two bedroom, 1 bath ADU. LN confirmed that there are two staff sleeping in the office. On January 21, 2026, Licensee Kourosh Ebadat informed the Department via email that conversion had been completed and was ready for inspection On January 22, 2026, the Department requested a new fire clearance inspection for the office conversion. On March 18, 2026 the Department received the approved fire clearance. During today's visit, LPA toured the new two bedroom, 1 bath ADU (Which is formerly the office, based on the facility sketch), which is being for staff use only. No deficiencies cited. This report was reviewed with Administrator Shujen Collado. A copy of the report was provided.the state’s words, verbatim · CDSS document, Mar 24, 2026

Type of visit: Case Management - Other

On March 11, 2026, Licensing Program Analyst Manuel Monter conducted an unannounced case management -other visit to follow up on the pending fire clearance. LPA met with Administrator Shujen Collado. LPA toured the construction project in the office room of the facility. LPA asked the status of the current remodel. LPA spoke to Licensee Corey who confirmed the fire department conducted there inspection 2 weeks ago. Licensee stated he would send a copy to LPA. No deficiencies cited. This report was reviewed with Administrator Shujen Collado. A copy of the report was provided.the state’s words, verbatim · CDSS document, Mar 11, 2026

Type of visit: POC

Licensing Program Analyst Manuel Monter conducted a POC case management visit to clear deficiencies cited on August 4, 2025, during an annual inspection visit. LPA explained the purpose of the visit. The facility was cited the following Type B deficiencies on August 4, 2025 with the following POC dates: 87202 Fire Clearance (a), POC due date August 11, 2025. 87305 Alterations to Existing Buildings or New Facilities (a), POC due date August 11, 2025 87412 Personnel Records (a)(11), POC due date August 11, 2025. 1569.695(c), POC due date August 11, 2025. During today's visit, LPA toured the facility inside and out, including the garage/Office area, and the backyard shed. LPA observed the facility shed was only being used as a storage space. LPA received plan of corrections by POC date. Deficiencies cleared during todays visit. No deficiencies were cited during todays visit. This report was reviewed with Staff Ema Danga. A copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 19, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator Shujen Collado. During the visit, LPA observed 6 residents and 3 staff. LPA explained the purpose of the visit. Ebadat Residential Care Home #6 is a level 4i home. LPA toured the facility inside out with ADM which included the Living room, kitchen, dining room, 3 restrooms and 4 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. 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 73 degrees F, and hot water temperature was measured at 109 degrees F in resident bathrooms. Fire extinguisher was serviced in August 2025. 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 August 20, 2024. LPA reviewed facility records for 3 staff and 3 residents. LPA asked for Staff S1's completed health screening form was. LPA pointed out S1's health screening did not have the evaluation of general health/ evaluation of ability to preform work / note any health condition/ the physician's stamp/signature. ADM stated S1 would get a new updated health screening in 1 week. Page 1 Out of 3. LPA reviewed 3 resident medications and centrally stored medication records. LPA reviewed 3 resident P&I records. While touring the facility office, LPA observed two partition walls and an additional door. These two walls and door way isn't reflected on the facility sketch. LPA observed in inside the partitioned bedroom a staff member. ADM stated two staff members use the office as a sleeping area. LPA also noted that a staff member was sleeping in the office area. LPA spoke to Licensee (LN) Kourosh Ebadat. LN stated he just got a permit approval in May 2025, to convert it to a two bedroom, 1 bath ADU. LN confirmed that there are two staff sleeping in the office. LN confirmed the additional bedroom in the office area, at its current state does not have a permit. While touring the sitting room, LPA observed, a partition wall. Note, this partition is not noted on the facility fire clearance. Furthermore, the fire clearance notes an opening between the sitting room and the living room. Based on empirical observation, there is a wall between both rooms. LN stated the sitting room-living room did not have an opening for crossing. LN stated there was a slight opening approximately 3 feet tall, and 8 foot wide. LN stated he did block that opening. LN also confirmed he did put a partition - half wall in the sitting room. LPA toured the facility shed in the backyard. LPA noted there was a mattress, cloths, medications. LPA also observed a power cord from the facility, heading inside the shed. LPA also noted there was a fan, a heater pointed towards the bed inside the storage shed. ADM confirmed there is a staff who sleeps in the shed. LPA provided ADM with copy of PIN 25-08-ASC. Page 2 Out of 3. LPA requested copies of the following forms: 1. LIC500, Personnel Summary 2. LIC308, 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. LIC309, Administrative Organization Deficiencies cited during today's visit, see LIC809-D. This report was reviewed with Licensee (LN) Kourosh Ebadat. and a copy of the signed report was provided. Appeal rights were provided. Page 3 Out of 3. END OF REPORT.the state’s words, verbatim · CDSS document, Aug 4, 2025

Allegation investigated: Facility did not ensure assistance is provided to residents in meeting or arranging his/her medical and health needs.

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 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 reportthe state’s words, verbatim · CDSS document, Jun 4, 2025 · control 26-AS-20250228175119

Type of visit: Case Management - Deficiencies

On 3/5/2025, Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted a unannounced complaint investigation. During this time deficiencies were observed and a case management for deficiencies was conducted and discussed the deficiencies with designated administrator (DADM) Shujen Collado. During file and record review LPA observed Staff 2 (S2) was not associated to the facility and no application to transfer the criminal background was submitted to CCLD for approval. LPA observed an incident report was not submitted to CCLD for 1 out of 6 resident (R1) for elopement that happened on 1/14/2025. S2 stated that he/she started working in the facility February 28, 2025, but is associated to a different facility under the same ownership/licensee. DADM stated that S2s application to be associated to the facility has not been submitted to CCLD prior to S2 working at the facility. S2 has a clear criminal background record on file. Citations are being issued based on the following California Code of Regulations (CCR) Title 22 87355 (e)(2) and 87211(a)(D). Violation of Section 87355(e) shall result in an immediate assessment of civil penalties of one hundred dollars ($100) per violation per day for a maximum of five (5) days for a total of $500.00. An exit interview was conducted with DADM Shujen Collado, a copy of the report and appeals rights were provided.the state’s words, verbatim · CDSS document, Mar 5, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Mar 5, 2025

87355 Criminal Record Clearance (e) All individuals...pursuant to Health and Safety Code Section 1569.17(b) shall prior to working... in a licensed facility: (2)Request a transfer of a criminal record clearance...This section is not met as evidenced by: Based on interview & record review, DADM stated S2 started working at the facility on 2/28/2025 and application to transfer or associate S2 has was not submitted to CCLD prior to S2 working at the facility which pose/poses an immediate health and personal right risks to persons in care.the state’s words, verbatim · CDSS document, Mar 5, 2025

Plan of correction: DADM stated that S2s application will be submitted to CCLD within 24 hours.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(D) · Plan of correction due date: Mar 5, 2025

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency... reports... (1) A written report shall be submitted to the licensing agency and to the person responsible…within seven days of the occurrence...(D)Any incident which threatens the welfare, Based on the interview and record review, DADM stated that incident report of R1s elopement incident on 1/15/25 was not submitted to CCLD and to person responsible for resident within 7 days, which pose/poses a health, safety & personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 5, 2025

Plan of correction: con't. safety or health of any resident, such as…unexplained absence of any resident. This section is not met as evidenced by: DADM stated incident reports will be submitted in a timely manner to CCLD and responsible party within seven days of the occurrence.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Maria (Mita) Partoza a conducted an unannounced required 1 year inspection visit and met with administrator Shu Jen Collado and stated the purpose of the visit. The facility is licensed to serve adults 60 and over of which 3 may be non-ambulatory. LPA observed 5 out of 6 residents are present at the facility that have neurocognitive impairment, 3 staff (S1 to S3) were present and attending to residents. At 2:00 p.m. LPA toured the facility inside and outside with S1 including but not limited to the kitchen, bathroom, dining room, living room, 4 residents rooms, office/bedroom and laundry area backyard and exterior walkways. The temperature inside the home was at 73 degrees Fahrenheit. The kitchen was observed to be sanitary and organized, knives and sharps were locked and not accessible to residents. LPA observed 2 days of perishable food and 7 days of non-perishable food. Under the sink cabinet is used to store pots and pans. The kitchen water temperature measured at 114.6 degrees Fahrenheit. The facility is maintained, sanitary. The bathrooms are equipped with grab bars, non-skid mats. The water temperature in the bathroom measured between 114.6 degree Fahrenheit. Resident's room (R1 to R6) have sufficient storage, organized and sanitary. LPA observed that medications are kept locked and inaccessible to residents. The first aid kit is complete and is accessible to staff. The backyard, walkways, ramps and patio are free from debris and obstruction. The facility screen windows were observed to be in good repair. The washer and dryer are in god working condition. Laundry soap and cleaning supplies are locked and not accessible to residents in care. page 1 of 2 The facility is equipped with a fire, smoke and carbon monoxide alert system that is in good working condition, night lights on the hallway are in good working condition. The hallway are free from obstruction. LPA reviewed 3 out of 6 resident records such as but not limited to the centrally stored medication and destruction record (CSMDR), admission agreement, needs and services plan, health screening and observed records the following; 2 out 3 (R1 to R3) were missing consent form, appraisal needs and services plan. R1 to R3 are missing information on the personal rights document. R1-R3 are missing information on the emergency ID. R3 is missing the second page of the physicians medical report. LPA reviewed 4 out of 8 staff records including but not limited to required training, first aid/CPR training, health screening and background clearance. 4 out 8 (S1 to S5) staff have criminal record clearance/fingerprints that are completed and updated. 1 out of 8 staff (S5) started at the facility 9/1/2024 and has criminal background/fingerprint clearance. Licensee stated, he/she is in the process of transferring the criminal record clearance of S5. LPA was able to verify eligibility of S5 through Guardian. S5 was observed providing care and supervision to residents in care. Deficiency is cited during today's visit base on California Code of Regulation (CCR) Title 22 87355(c)(1) and 87506(a). An exit interview was conducted with administrator Shu-Jen Collado. A copy of the report and appeals rights were provided. page 2 of 2 end of reportthe state’s words, verbatim · CDSS document, Sep 21, 2024