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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 430700017
Report Date: 05/20/2021
Date Signed: 07/01/2021 09:59:04 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
07/30/2019 and conducted by Evaluator David Marrufo
COMPLAINT CONTROL NUMBER: 26-AS-20190730171921
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: 33DATE:
05/20/2021
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Elaine SabankayaTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Residents charged for services not provided.
Activities are not offered
Staff Threatening residents with evictions.
Staff yell at the residents.
Residents are using drugs on the premises.
Incidents are not being reported.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) David Marrufo conducted a complaint investigation visit and met with Elaine Sabankaya.

On 07/30/2019, the Department received a complaint with the above allegations. LPA Marrufo conducted an initial complaint visit on 08/09/2019. From 08/09/2019 through 05/14/2021, LPA Marrufo interviewed 9 residents and 8 staff. LPA Marrufo also obtained the following documents as part of the complaint investigation: Eviction Notices, Bed Check Logs, Admission Agreements, Facility Program Design, and LIC624 Incident Reports.

See LIC9099-C for more information. Page 1 of 4.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2021
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 7
Control Number 26-AS-20190730171921
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: 05/20/2021
NARRATIVE
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6 out of 9 residents stated to have not received therapeutic services from the facility. 3 out of 9 residents stated to receive therapeutic services from the facility. 7 out of 8 staff stated that the facility does not provide therapeutic services to residents. 1 out of 8 staff was not sure.

The Admission Agreement does not mention therapy as a basic service provided to residents. The facility Program Design states that it offers yearly therapy projects organized and operated by the San Jose State University (SJSU) Occupational Therapy Program. 1 out of the 8 staff stated that SJSU suspended its therapy program with the facility in August 2020 due to COVID-19. LPA Marrufo requested documents from facility staff regarding the history of visits the SJSU Occupational Therapy program made to the facility, but the staff was unable to provide the records.

5 out of 9 residents stated that the facility does not offer residents activities. 4 out of 9 residents stated that the facility offers activities to residents. 6 out of 8 staff stated activities are not offered to residents. 2 out of 8 staff stated activities are offered to residents.

LPA Marrufo conducted a virtual Facetime tour of the facility on 04/23/2021 and did not observe an activity calendar posted on the bulletin board near the dining room. LPA Marrufo observed residents sitting at tables 6 feet apart from one another in the courtyard.

The Admissions Agreement states that residents are expected to participate in a house program, community program, or personal program weekdays between 9:30 AM and 11:00 AM. The facility Program Design states that residents are encouraged to participate in socialization and physical activities and will be encouraged to participate and contribute to the planning, preparation and critique of planned activities. The Program Design contains a sample of an Activities Schedule.

See LIC9099-C for more information. Page 2 of 4.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2021
LIC9099 (FAS) - (06/04)
Page: 7 of 7
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
07/30/2019 and conducted by Evaluator David Marrufo
COMPLAINT CONTROL NUMBER: 26-AS-20190730171921

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: 33DATE:
05/20/2021
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Elaine SabankayaTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff are failing to report AWOLs.
INVESTIGATION FINDINGS:
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1 out of 8 staff stated to have observed staff failing to report when residents leave the facility without notifying the facility. 7 out of 8 staff stated to have not observed staff failing to report when residents leave the facility without notifying the facility.

The Admission Agreement states that residents can leave the facility after curfew but must notify the House Manager. The facility Bed Check Logs indicate that there were AWOLs on the dates of 07/04, 20, 22, 23, 24, 25, 26, 27, 28, and 31/2019. LPA Marrufo reviewed the facility file and found only one LIC624 Incident Report for an AWOL, which was dated 02/27/2019. LPA Marrufo obtained an incident report from the facility regarding residents missing from the facility for the date of 07/23/2019. 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: 05/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2021
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 7
Control Number 26-AS-20190730171921
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/27/2021
Section Cited
CCR
80061(b)(1)(E)
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...a report shall be made to the licensing agency within the agency's next working day: during its normal business hours. In addition, a written report containing the information
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Licensee agrees to conduct training with facility staff to ensure staff report all incidents of missing residents to licensing. Licensee agrees to submit copies of training records including training topic,
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specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event. Any unusual incident or client absence which threatens the physical or emotional health or safety of any client. This requirement was not met as evidenced by: Licensee failed to submit incident reports for incidents of missing residents, as recorded in facility records, which poses a potential safety risk to residents in care.
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roster of staff trained, date(s) of training, and name and qualifications of trainer 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: 05/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 26-AS-20190730171921
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: 05/20/2021
NARRATIVE
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Based on records review, interviews and observations there is preponderance of evidence to prove the alleged violation did occur, therefore the allegation is SUBSTANTIATED.

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

Exit interview conducted with Elaine Sabankaya and a copy of this report and appeal rights provided.

Page 2 of 2.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 26-AS-20190730171921
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: 05/20/2021
NARRATIVE
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1 out of 9 residents stated to have observed staff threaten residents with eviction. 8 out of 9 residents stated to have not observed staff threaten residents with eviction. 1 out of 8 staff stated to have observed staff threatening residents with eviction. 7 out of 8 staff stated to have not observed staff threatening residents with eviction.

9 out of 9 residents stated to have not observed staff yelling at residents. 7 out of 8 staff stated to have not observed staff yelling at residents. 1 out of 8 staff stated to have observed staff yelling at residents.

4 out of 9 residents stated to have observed residents using drugs at the facility. 2 out of those 4 residents stated that staff respond to residents using drugs in the facility by issuing verbal warnings and requiring drug tests. 5 out of 9 residents stated to have not observed residents using drugs at the premises and 1 out of 9 residents stated to not know if residents use drugs on the premises.

4 out of 8 staff stated to have observed residents using drugs at the facility. 2 out of those 4 stated that staff respond to residents using drugs by issuing verbal warnings and requiring drug tests. 4 out of 8 staff stated to have not observed residents using drugs in the facility.

The Admission Agreement states in the House Rules that residents are not permitted to use drugs at the facility. Eviction notices from the facility indicate that residents were issued eviction notices for doing drugs at the facility on 03/20/2019, 04/16/2019, and 04/30/2019.

8 out of 8 staff stated to have not observed the facility not report incidents to the Department.

LPA Marrufo reviewed the facility file and found two incident reports from 2019 that the facility reported to the Department.

See LIC9099-C for more information. Page 3 of 4.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 26-AS-20190730171921
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: 05/20/2021
NARRATIVE
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Based on information from interviews conducted with residents and staff, and records reviewed, 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, therefore the allegations are UNSUBSTANTIATED.

This report was reviewed with Elaine Sabankaya and a copy of the report was provided.

Page 4 of 4.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 7