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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 430700017
Report Date: 03/07/2025
Date Signed: 03/07/2025 03:25:42 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
11/06/2024 and conducted by Evaluator Christine Kabariti
COMPLAINT CONTROL NUMBER: 26-AS-20241106123703
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: 18DATE:
03/07/2025
UNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Maria CanizalesTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility staff is not competent to provide the services necessary to meet residents needs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the finding of the above allegation. LPA met with Program Director, Maria Canizales.

On 11/06/2024, the Department received the complaint regarding the above allegation. On 11/14/2024, the initial complaint investigation was conducted.

Documents were obtained for this investigation to include resident roster, staff training record, and resident (R1)’s physician’s report, appraisal/needs and services plan, identification and emergency contact information, and progress notes.

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Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Kabariti
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025
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 4
Control Number 26-AS-20241106123703
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: 03/07/2025
NARRATIVE
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It was alleged that staff (S1) is not competent in handling residents who are going through a crisis. It was stated that instead of de-escalating a crisis, S1 escalates the resident’s crisis by asserting control by holding his/her ground when R1 is actively going through an episode, avoiding eye contact, and speaking to R1 at a loud volume. This was observed by witnesses during an incident on 10/15/2024.

On 10/15/2024, an incident occurred wherein R1 was being verbally aggressive towards the staff after medication and items that could be of danger to the resident and others were found and confiscated inside R1’s room.

Based on interview with staff (S1), on 10/15/2024, during rounds, S1 observed medications and multiple items which could be of danger to the resident and others inside R1’s room. When S1 informed R1 that the items were going to be confiscated, R1 became upset.

S1 stated that R1 was yelling in S1’s face within a few feet apart. When R1 was yelling in S1’s face, S1 stated that he/she did not step back and stood his/her ground. S1 states he/she did not step back because he/she knew that R1 would not be physical with S1. S1 stated that during the incident S1’s tone of voice raised “a little”, but S1 denied yelling or being angry at R1. S1 stated that he/she initially approaches the residents in a low tone of voice but if the resident is not listening, S1’s tone of voice increases to be more persuasive.

S1 states that during a resident’s crisis, S1 has observed that the treatment team and crisis team walks away from the situation. S1 states that he/she does not walk away but instead confronts the situation because of the need to “take care of it”. S1 states he/she does not step back because he/she knows that the residents will not be physical with the staff and are only verbally aggressive.

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SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Kabariti
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 26-AS-20241106123703
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: 03/07/2025
NARRATIVE
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Based on record review and interview, the facility staff (including S1) are not trained in handling crisis situations, but they take away from experience. It’s stated that when residents are going through a crisis, the staff are verbally trained to step away from the situation and to grab somebody. It’s stated that the program director has completed crisis prevention intervention training from a previous employer and if a resident is going through a crisis, the staff are told to call the program director to step in, however, if the program director is not available, staff are trained to step away, grab someone, call the crisis line, trust team, and/or 911.

The Department has investigated the above allegation. Based on interview, record review and observation the preponderance of evidence standard has been met, therefore, the above allegation is substantiated. A deficiency was 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.

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SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Kabariti
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 26-AS-20241106123703
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: 03/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/14/2025
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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Program director has an active certification for "Crisis Prevention Intervention Non-Violence". Licensee plans to train S1 on crisis intervention by 03/14/2025. Licensee plans to complete training for all staff before end of March 2025.
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Based on interview, record review and observation the licensee did not ensure staff (S1) followed the facility's protocols of stepping away and calling appropriate parties for assistance when R1 was going through a crisis which poses/posed a potential health, safety, and personal rights risk to persons in care.
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Licensee will submit S1's training document to LPA Kabariti via email by POC due date of 03/14/2025.
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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: Christine Kabariti
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025
LIC9099 (FAS) - (06/04)
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