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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 430700017
Report Date: 09/10/2021
Date Signed: 09/10/2021 05:39:41 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/08/2021 and conducted by Evaluator David Marrufo
COMPLAINT CONTROL NUMBER: 26-AS-20210908151310
FACILITY NAME:ALI BABA # 1FACILITY NUMBER:
430700017
ADMINISTRATOR:CHERALYNN SABANKAYAFACILITY TYPE:
735
ADDRESS:260 SOUTH 11TH STREETTELEPHONE:
(408) 289-1644
CITY:SAN JOSESTATE: CAZIP CODE:
95112
CAPACITY:38CENSUS: 31DATE:
09/10/2021
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Renee SabankayaTIME COMPLETED:
06:00 PM
ALLEGATION(S):
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Facility refused to reaccept client back to the facility
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Renee Sabankaya, Designated Administrator.

During visit, LPA Marrufo interviewed Renee Sabankaya and a witness. Renee Sabankaya stated that resident R1 was refusing medications and not eating for approximately 3 weeks. She states the she refused to take R1 back from the hospital because she was concerned R1 would continue to refuse medications and food. She stated that the facility had not issued R1 an eviction notice. She stated that the hospital offered R1 a bed at a crises residential care home, but R1 refused. The interviewed witness also stated that the facility refused to reaccept R1 back from the hospital and that on 09/08/2021, the hospital offered R1 a bed at a crisis residential home, but R1 refused. See LIC9099-C for more information.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2021
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-20210908151310
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: ALI BABA # 1
FACILITY NUMBER: 430700017
VISIT DATE: 09/10/2021
NARRATIVE
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Based on records review, interviews and observations there is preponderance of evidence to prove the alleged violations did occur, therefore the allegation is SUBSTANTIATED.

During visit, LPA Marrufo consulted with Designated Administrator Renee Sabankaya about the importance of having a resident be accepted into another care facility before the resident can be discharged.

See 9099-D for deficiencies cited per the California Code of Regulations, Title 22.

This report was reviewed with Designated Administrator Renee Sabankaya and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 26-AS-20210908151310
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: ALI BABA # 1
FACILITY NUMBER: 430700017
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/17/2021
Section Cited
CCR
80068.5(a)(4)
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Except for children's residential facilities, the licensee may, upon 30 days written notice to the client, evict the client only for one or more of the following reasons...Inability to meet the client's needs.
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Licensee agrees to submit a statement of understanding of the eviction procedures as stated in CCL regulation 80068.5 to CCL by POC date and ensure that resident R1 is accepted back to the facility
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This requirement was not met as evidenced by: Licensee did not ensure that resident R1 was given an eviction letter before the facility refused to readmit R1 back from the hospital, which posed a potential safety risk to residents in care.
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if R1 is not discharged from the facility in a manner that is compliant with CCL regulations.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3