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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 430700017
Report Date: 07/27/2023
Date Signed: 07/28/2023 08:06:42 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
06/26/2020 and conducted by Evaluator Simranjit Rai
COMPLAINT CONTROL NUMBER: 26-AS-20200626095144

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: 38DATE:
07/27/2023
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Adminstrator Maria CanizalesTIME COMPLETED:
07:00 PM
ALLEGATION(S):
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Lack of supervision
Facility does not have sufficient food supply for emergencies
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Simi Rai and Manuel Monter and Licensing Program Manager (LPM) Romeo Manzano conducted an unannounced inspection/investigation visit to conclude and deliver investigation of the above allegations. LPAs and LPM met with Administrator Maria Canizales and stated the purpose of today's visit.

Lack of supervision

On 6/2020, the Department received LIC624 Unusual Incident/Injury Report that on 6/6/2020, staff stated that during 1:00AM check, R1 was not on site. R1 was located at 10th street and San Carlos by law enforcement at 5:50AM. R1 returned back to the facility at 06:00AM.

Continuation on LIC-9099-C
Page 1 of 2.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 26-AS-20200626095144
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: 07/27/2023
NARRATIVE
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Page 2 of 2.

On 07/06/2020, the Department interviewed former ADM stated that R1 had a habit of disappearing and was not compliant with his/her medication. ADM stated that he/she has a habit of disappearing wherein he/she usually away 15-20 minutes, law enforcement will bring him/her back to the facility.

Based on interview and document review, the facility did not provide the supervision for R1. According to the report submitted to the Department LIC 624 Unusual Incident/Injury Report on 6/26/2020, the former ADM stated the facility will utilize any available resources to obtain case management assistance for R1 since R1 has been having ongoing issues with medication compliance.

Facility does not have sufficient food supply for emergencies

On 07/06/2020, the Department conducted investigation interview with Administrator (ADM) and Licensee (L1). L1 stated that the facility store food supplies in the facility basement which is about 2000 square feet. ADM stated that they have weekly grocery shopping because they are feeding a lot of residents. L1 stated that it is impossible to store large amount food supplies, they just have to order food supplies for both facilities weekly. ADM stated that they had food supplies but did not have a back up. ADM stated that they just basically order them.

On 07/27/2023, during the annual inspection, LPAs Christine Dolores and Grace Donata observed the facility did not have emergency food supply. ADM stated the emergency food supply needs to be purchased for the facility. LPAs observed facility is not able to be self-reliant for a period of not less than 72 hours with the current supply of non-perishable food.

Based on interviews and observation/inspection of the facility, the preponderance of evidence standard has been met therefore the above allegations is found to be SUBSTANTIATED.

Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 9099-D.
This report was reviewed with Administrator Maria Canizales and a copy of the report was provided. Appeal Rights was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 26-AS-20200626095144
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: 07/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/28/2023
Section Cited
CCR
85078(a)(1)
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85078 Responsibility for Providing Care and Supervision (a) In addition to Section 80078, the following shall apply:
(1) The licensee shall provide those services identified in the client's needs and services plan as necessary to meet the client's needs.
This requirement is not met as evidenced by:
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Administrator will submit a written plan stating understanding of regulation and the plan of action of facility to ensure the client's needs and services are met by POC date. Administrator verbally understands the POC.
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Based on interview and document review, the facility did not provide the supervision for R1 when R1 left the facility without supervision which poses a immediate Health, Safety, or Personal Rights risk to persons in care.
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Type A
07/28/2023
Section Cited
HSC
1565(a)(2)
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1565(a)(2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure...
This requirement is not met as evidenced by:
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Administrator will submit a written plan stating understanding of regulation and the plan of action of facility to ensure the facility has food supply to be self-reliant for a period of not less than 72 hours by POC date. Administrator verbally understands the POC.
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Based on observation, facility is not able to be self-reliant for a period of not less than 72 hours with the current supply of non-perishable food which poses an immediate Health, Safety or Personnel 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: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5