430700017-4-1-2021-26-AS-KHOS-C2PHBP-20210504060326

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 430700017
Report Date: 04/01/2021
Date Signed: 04/01/2021 10:20:42 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/09/2019 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20190709101050

FACILITY NAME:	ALI BABA # 1		FACILITY NUMBER:	430700017
ADMINISTRATOR:	CHERALYNN SABANKAYA		FACILITY TYPE:	735
ADDRESS:	260 SOUTH 11TH STREET		TELEPHONE:	(408) 289-1644
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95112
CAPACITY:	38	CENSUS: 20	DATE:	04/01/2021
		UNANNOUNCED	TIME BEGAN:	09:51 AM
MET WITH:	Mustafa Sabankaya		TIME COMPLETED:	10:15 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Licensee forces clients to work at the facility
Facility exposed clients to chemicals
Facility staff yells at clients in care
Facility has bed bugs
Facility failed to be adequately staffed

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit over telephone and met with Licensee Mustafa Sabankaya. The visit was conducted over telephone due to the ongoing COVID-19 Shelter-in-Place order throughout the county and state.

From 07/16/2019 through 03/11/2021, LPA Marrufo conducted complaint investigation visits and interviews with residents and staff and requested documents. In total, LPA Marrufo interviewed 6 residents, 11 staff, and 4 witnesses.

See LIC9099-C for more information. Page 1 of 3.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 04/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2021

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 3

Control Number 26-AS-20190709101050

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: ALI BABA # 1	FACILITY NUMBER: 430700017
	VISIT DATE: 04/01/2021

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

6 out of the 6 residents, 10 of the 11 staff, and 4 of the 4 witnesses stated to have not observed the licensee forcing the residents to work at the facility. 1 out of the 11 staff reported that there were two residents that facility staff coerced into working for the facility.

Based on interviews with staff, residents, and witnesses, as well as review of records, the Department determines that the above allegations are unsubstantiated, meaning that although the allegations listed above may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

No Deficiencies cited under California Code of Regulations Title 22

This report was reviewed with Licensee Mustafa Sabankaya. A copy of the report will be emailed to him so that it can be signed and returned to CCL.

SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 04/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 26-AS-20190709101050

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: ALI BABA # 1	FACILITY NUMBER: 430700017
	VISIT DATE: 04/01/2021

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

During the investigation, 4 out of the 6 residents, 3 out of the 11 staff, and 4 out of 4 witnesses stated they had observed bed bugs at the facility. 5 residents, 3 staff, and 4 witnesses stated that staff spray for bed bugs. LPA Marrufo received bank statements from the facility for payments made monthly to a professional extermination service dated July 2019. LPA Marrufo obtained a letter on official letterhead from the extermination service provider stating that the provider has been contracted to provide pest extermination services at the facility monthly since 2012.

6 out of the 6 residents, 11 out of the 11 staff, and 4 out of the 4 witnesses stated to have not observed staff spraying residents directly on their skin for bed bugs with any kind of treatment.

6 out of 6 residents and 11 out of 11 staff stated to have not observed a time when there was not an adequate amount of staff at the facility. 1 out of 4 witnesses reported to have observed times when there were not enough staff scheduled at the facility to meet the needs of all the residents. However, 3 out of 4 witnesses stated to have not observed a time when there was not an adequate amount of staff at the facility. The licensees stated to not have copies of actual staff work schedules from 2019, but provided a statement that there is always one dedicated staff working in the medication room and another medication room staff floating between the facility medication room and the medication room of Club Riviera, another facility owned by the licensees located nearby within walking distance. Licensee also stated that there are two case managers working Monday through Friday from 8:00 AM until 5:00 PM with additional support from designated administrators working 40 to 70 hours per week. LPA obtained a copy of the staff work schedule for March 2021 and saw that the hours reflected the statements made by Licensee.

6 out of 6 residents, 10 out of 11 staff, and 2 out of 4 witnesses stated to have not observed times when staff yell at residents. However, 1 out of the 11 staff and 2 out of 2 witnesses stated to have observed times when staff yell at residents. However, there were no actual dates and times provided of incidents of staff yelling at residents.

See LIC9099 for more information. Page 2 of 3.

SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 04/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3