430700017-8-29-2023-26-AS-KHOS-CVZNCD-20230925102033

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 430700017
Report Date: 08/29/2023
Date Signed: 08/29/2023 11:43:22 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 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
05/10/2023 and conducted by Evaluator Christine Dolores

COMPLAINT CONTROL NUMBER: 26-AS-20230510165306

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: 32	DATE:	08/29/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Maria Canizales		TIME COMPLETED:	11:50 AM

ALLEGATION(S):

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Staff did not provide 60 day notice prior to increasing the resident's rate.
Activities are not being provided to the residents.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the finding regarding the above allegation. LPA met with Program Director, Maria Canizales. This report was issued at Club Riviera #435202511. The Program Director is the same for Ali Baba #1.

On 05/10/2023, the Department received a complaint regarding the above allegations. It was alleged that the facility did not provide a 60-day notice prior to increasing the resident’s rate and activities are not provided to the residents. On 05/19/2023, the initial complaint investigation was conducted.

From 05/19/2023 – 08/29/2023, documents were obtained to include resident (R1)’s June 2022 – April 2023 billing invoices, R1 – R4’s admission agreement, physician’s report, appraisal/needs and services plan, email correspondences, and activities calendar. SEE LIC9099-C.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

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-20230510165306

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: ALI BABA # 1	FACILITY NUMBER: 430700017
	VISIT DATE: 08/29/2023

NARRATIVE

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Staff did not provide 60-day notice prior to increasing the resident’s rate
Based on review of records, resident (R1)’s family was responsible for R1’s rent at the facility. The review of records shows that on 10/11/2022 R1 was billed an increased amount than what was agreed upon during admission. Based on interview, R1 was verbally informed of the increased services due to behaviors of R1. Upon questioning what the increased services would entail, staff was unable to provide an explanation. The review of records show that R1 was not provided a written notice of the increased rate prior to receiving the monthly invoice.

R1’s admission agreement at the facility states that for any rate increase that exceeds 10% in any 12-month period, the resident will receive a 60-day written notice.

Based on interview and record review, R1 was not provided a 60-day written notice prior to being billed an increased amount per the signed admission agreement.

Activities are not being provided to the residents

On 05/24/2023, a staff (S1) was interviewed. It was stated that the facility does not currently provide activities for the residents due the COVID-19 restrictions. Based on record review and observation, the facility also does not have an activities calendar.

Based on interview and record review, the facility began implementing activities on 06/06/2023.

The Department has investigated the above allegations. Based on record review, interview and observation the preponderance of evidence has been met, therefore, the above allegations are SUBSTANTIATED.

Deficiencies are being cited per California Code of Regulations, Title 22.

This report was reviewed with Program Director, Maria Canizales and a copy of the report was provided along with the appeal rights.

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 5

Control Number 26-AS-20230510165306

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 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: 08/29/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/05/2023 Section Cited CCR 80068(c)(4)	1 2 3 4 5 6 7	(c) Admission agreements must specify the following: (4) Modification conditions, including requirement for provision of at least 30 calendar days prior written notice to the client or his/her authorized representative of any basic rate change. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee has revised admission agreement and submitted the document to Licensing for approval. Licensee will submit a statement of understanding of Section 80068(c)(4) to LPA Dolores via email by POC due date.
	8 9 10 11 12 13 14	Based on interview, record review, and observation the licensee did not ensure R1 was provided at least a 30 calendar day written notice prior to increasing R1's rent which poses/posed a potential health, safety, and personal rights risk to persons in care.	8 9 10 11 12 13 14
Type B 09/05/2023 Section Cited CCR 85079(d)	1 2 3 4 5 6 7	(d) In facilities with a licensed capacity of seven or more clients, notices of planned activities shall be posted in a central facility location readily accessible to clients, relatives, and representatives of placement and referral agencies. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee has corrected deficiency prior to visit. Licensee has provided the faciltiies activities calendar to LPA Dolores from June - August 2023. POC CLEARED.
	8 9 10 11 12 13 14	Based on record review, interview, and observation the licensee did not ensure residents are provided planned activities which poses/posed a potential health, safety, and personal rights risk to persons in care.	8 9 10 11 12 13 14

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: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 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
05/10/2023 and conducted by Evaluator Christine Dolores

COMPLAINT CONTROL NUMBER: 26-AS-20230510165306

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:	DATE:	08/29/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Maria Canizales		TIME COMPLETED:	11:50 AM

ALLEGATION(S):

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Administration are not answering resident's family members in a timley manner

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the finding regarding the above allegation. LPA met with Program Director, Maria Canizales. This report was issued at Club Riviera #435202511. The Program Director is the same for Ali Baba #1.

On 05/10/2023, the Department received a complaint regarding the above allegations. It was alleged that the facility staff are not answering resident (R1’s) family member in a timely manner. On 05/19/2023, the initial complaint investigation was conducted.

From 05/19/2023 – 08/29/2023, documents were obtained to include email correspondences and letters between the facility and R1's family member.

SEE LIC9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 26-AS-20230510165306

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: ALI BABA # 1	FACILITY NUMBER: 430700017
	VISIT DATE: 08/29/2023

NARRATIVE

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Based on interview, the facility does try to communicate with family members in a timely manner either via telephone call or emails. S1 states the facility was having technical difficulties with their telephone in which they were receiving telephone calls but no voicemails.

Based on record review, there was not enough evidence to prove R1’s family member was not being answered by the facility's administration in a timely manner either via telephone call or via email.

The Department has investigated the above allegations. Based on interview, observation and record review the above allegations is unsubstantiated. An unsubstantiated finding indicates that although the allegation may have happened and/or is valid there was not a preponderance of evidence to prove the alleged violations did or did not occur.

No deficiencies were cited per California Code of Regulations, Title 22.

This report was reviewed with Program Director, Maria Canizales and a copy of the report was provided.

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 5