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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 430700017
Report Date: 05/06/2022
Date Signed: 05/06/2022 01:31:38 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
04/29/2022 and conducted by Evaluator David Marrufo
COMPLAINT CONTROL NUMBER: 26-AS-20220429113811
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: 27DATE:
05/06/2022
UNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Renee SabankayaTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Facility is in disrepair.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Renee Sabankaya.

During visit, LPA Marrufo toured 4 out of 4 facility buildings. In building 1, LPA Marrufo observed 7 bedrooms and observed missing window screens in Room 5, which facility staff reported is unoccupied. In Building 2, LPA Marrufo toured 5 bedrooms and observed a missing window screen in Room 1. LPA Marrufo observed a power outlet that was uncovered in the hallway of Building 2. LPA Marrufo toured Building 3, and toured 19 out of 19 bedrooms, except for rooms 1, 2, and 15, which were locked. Rooms 6, 10, 14, and 18 had missing window screens. Building 5 was toured and had no missing window screens.

See LIC9099-C for more information. Page 1 of 2.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022
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 5
Control Number 26-AS-20220429113811
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: 05/06/2022
NARRATIVE
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LPA Marrufo toured the outside of each building. On the outside of building 3, LPA Marrufo observed three holes approximately 3-5 inches in diameter on the north wall of the building. On Building 1, LPA Marrufo observed a rectangular hole in the building approximately two feet high and two feet wide. The hole had pipes running through it and led to the area underneath the floor of the building.

LPA Marrufo observed two light fixtures along the front of the facility property which did not have covers on them.

LPA Marrufo observed gutters on the north west side of Building 3 which had plants growing out of them approximately 1-2 feet high. The gutters on the north west side of Building 2 had coiled cables on them.

LPA Marrufo interviewed Designated Administrator Renee Sabankaya who stated the residents sometimes push out the screens and maintenance staff is working on replacing the screens. She stated the residents sometimes take off covers off of light fixtures.

Based on interviews and observations there is preponderance of evidence to prove the alleged violations did occur; therefore, the allegation is substantiated.

A deficiency was cited as per California Code of Regulations Title 22. See LIC9099-D for more information.

This report was reviewed with Renee Sabankaya and a copy of the report was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 26-AS-20220429113811
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: 05/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/13/2022
Section Cited
CCR
80087(a)
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80087(a) Buildings and Grounds: (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This regulation was not met as evidenced by: Licensee did not ensure that each resident
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Licensee agrees to replace all missing window screens, repair the holes in the exteriors of Buildings 2 and 3, remove debris from the gutters, and repair the two light fixtures with missing covers by POC date. Licensee shall submit photographic proof of
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bedroom has window screens installed, that the facility exterior walls do not have holes, that the gutters are kept free of obstructions, and that light fixtures are repaired, which poses a potential safety risk to residents in care.
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all repairs by POC date.
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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: 05/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
04/29/2022 and conducted by Evaluator David Marrufo
COMPLAINT CONTROL NUMBER: 26-AS-20220429113811

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: 27DATE:
05/06/2022
UNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Renee SabankayaTIME COMPLETED:
01:45 PM
ALLEGATION(S):
1
2
3
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5
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8
9
Facility is unsanitary.
INVESTIGATION FINDINGS:
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13
LPA Marrufo conducted an unannounced complaint investigation visit and met with Renee Sabankaya.

During visit, LPA Marrufo toured the inside and outside of Building 1, 2, 3, and 4. LPA Marrufo did not find any resident trash or excrement on the outside of the buildings. LPA Marrufo interviewed residents R1-R2 and asked if they have observed any residents throwing trash or excrement outside of the windows or observed any trash or excrement outside of the windows. R1 responded no to both questions. R2 stated to not know about both questions. LPA Marrufo interviewed staff S1-S3, who all stated that residents are given a trash bin in their rooms and staff will pick up the trash from the bins or clean up trash on the floor that residents did not put into the bins. S1-S3 stated to have not observed residents throw trash or excrement outside of the windows or seen any outside of the windows.

See LIC9099-C for more information. Page 1 of 2.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 26-AS-20220429113811
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: 05/06/2022
NARRATIVE
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Staff S1-S3 stated that they clean the bedrooms, bathrooms, and hallways of each building, but do not check the outside of the facility buildings for anything needing repairs.

Based on information from interviews conducted with staff, and observations, although the allegation listed above 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 Deficiencies cited under California Code of Regulations Title 22

This report was reviewed with Renee Sabankaya and a copy of the report was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5