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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 430700017
Report Date: 10/03/2024
Date Signed: 10/03/2024 04:52:29 PM

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
10/02/2024 and conducted by Evaluator Christine Dolores
COMPLAINT CONTROL NUMBER: 26-AS-20241002111818
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: 26DATE:
10/03/2024
UNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Maria CanizalesTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff did not notify the resident's responsible party regarding a medication refill in a timely manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to open the initial complaint investigation. LPA met with Program Director, Maria Canizales.

On 09/26/2024, the Department received the complaint. On 10/03/2024, the initial complaint investigation was conducted. The following documents were obtained to include the resident roster, staff schedule from 09/23/2024 - 09/29/2024, resident (R1)'s centrally stored medication record, medication administration record from September - October 2024, and email correspondences.

It was alleged that the facility staff did not notify the resident's responsible party regarding a medication refill until the medication was depleted. It was alleged that this incident occurred on 09/26/2024, 10/06/2023 and 06/09/2023.
PAGE 1 OF 2.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024
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-20241002111818
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: 10/03/2024
NARRATIVE
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On 10/03/2024, LPA Dolores interviewed 3 staff members. 3 out of 3 staff members state their procedures to follow-up with residents refills at least 7-10 days prior to the resident running out of medications.

Based on review of R1's medication administration record (MAR) and interview with S1, R1 did not receive his/her daily medication (medication #1) from 09/20/2024 - 09/26/2024 and daily medication (medication #3) on 09/26/2024. S1 stated that R1 was out of medication #1 and #3 and they did not receive his/her new medication until 09/27/2024.

On 10/03/2024, LPA Dolores reviewed R1's medication. Based on observation, it was found that R1 does not have a refill for bedtime medication (medication #2) and the last dose was given on 09/17/2024. Medication #2's instructions is for three times a day. LPA observed R1 has medication #2 for the morning and evening, but not for bedtime as the bedtime's medication pack is observed empty. The medication name, strength, quantity, and instructions for medication #2 are the same, but the medication packs are separated to morning, evening, and bedtime. Based on interview, staff (S4) stated that R1 doesn't like to come to the medication room during the evening times, even after they provide reminders. S4 states that because R1 doesn't take evening medication S4 administers the evening medication (medication #2) for bedtime, since R1 does not have anymore pills left in his/her bedtime medication pack.

The review of records shows that staff (S3) emailed R1's treatment team on 09/20/2024 (the day R1 ran out of medication #1) stating that R1 is out of 3 medications (#1, #2, and #3). On 09/26/2024, staff (S2) emailed R1's treatment team again stating that R1 is out of the 3 medications. A follow-up email was provided by R1's treatment team stating that R1's medication (#1 and #3) was sent to the pharmacy on Monday, 09/23/2024. Based on interview, S1 and S2 stated that the pharmacy refilled medication #1 and #3 on 09/23/2024 but the facility was not informed of the medication refill until 09/26/2024.

Based on interview, R1 has an appointment with his/her doctor on 10/05/2024 to refill medication #2 and to discuss another health related concern.

The Department has investigated the above allegation and the preponderance standard has been met, therefore, the above allegation is substantiated. Deficiencies were cited per California Code of Regulations, Title 22. See LIC9099-D. This report was reviewed with Program Director, Maria Canizales and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 26-AS-20241002111818
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: 10/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/04/2024
Section Cited
CCR
80075(b)
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(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement is not met as evidenced by:
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Licensee will retrain staff on the proper procedures to refilling resident's medication to ensure they do not run out. Licensee will submit the training records to LPA Dolores via email by POC due date of 10/04/2024.
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Based on interview, record review and observation the licensee did not ensure to assist resident (R1) as R1 was out of 2 medications (#1 and #3) which poses an immediate health, safety and personal rights risk to persons in care.
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Type A
10/04/2024
Section Cited
CCR
80065(a)
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(a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs. This requirement is not met as evidenced by:
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Licensee will retrain staff on the proper procedure in communicating with resident's responsible parties in a timely manner regarding medication refills. Licensee will submit the training records to LPA Dolores via email by POC due date.
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Based on interview, record review and observation the licensee did not ensure staff notified R1's treatment team and responsible party in a timely manner, prior to R1 running out of 3 medications which poses an immediate health, safety and personal rights risk to persons in care.
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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: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3