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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430700017
Report Date: 12/09/2021
Date Signed: 12/09/2021 04:57:53 PM

Document Has Been Signed on 12/09/2021 04:57 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
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: 37DATE:
12/09/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Renee SabankayaTIME COMPLETED:
05:16 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management Visit and met with Renee Sabankaya. The incident was in response to an Unusual Incident Report submitted by the facility on 12/04/2021 regarding resident R1 found by resident R2 and staff S1 to be choking at the facility. S1 called 911 for R1 and R1 was taken to the hospital.

During visit, LPA Marrufo interviewed R2, who stated to have observed R1 to be sitting in a chair in the courtyard area of the facility sometime between 7:30 PM and 8:30 PM on 12/04/2021. R2 observed R1 to be hunched over while sitting on a chair with R1's face appearing to have a purple color. R2 then ran to the facility medication room and notified S1 of R1's chocking. S1 then called 911 for R1 and emergency personnel arrived at the facility in around 7 to 10 minutes.

During visit, LPA Marrufo obtained copies of the following documents: Updated Unusual Incident Report submitted on 12/09/2021; R1's Physician's Report, Appraisal/Needs and Services Plan, and Emergency Contact Information; Staff Schedule; Resident Roster; and S1's Personnel Record.

No deficiencies were cited at this time as per California Code of Regulations Title 22.

This report was reviewed with Renee Sabankaya and a copy of the report was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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