430700017-5-12-2022-26-AS-KHOS-CEGQW9-20220516123135

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 430700017
Report Date: 05/12/2022
Date Signed: 05/12/2022 04:42:15 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
05/06/2022 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20220506153158

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:	05/12/2022
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Renee Sabankaya		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff pushed resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Renee Sabankaya.

During visit, LPA Marrufo interviewed residents R1-R10 and staff S1-S5. During interview, resident R2 stated that staff S1 pushed R2 onto the floor of the balcony near the facility medication room. R2 stated that R2 and S1 were arguing about not wanting to have S1 take R2's temperature, and then S1 grabbed R2 by the shoulders and pushed R2 onto the ground. R2 stated R2 landed on his/her back and S1 landed on top of R2 and yelled curse words at R2's face. R2 stated R2's right leg bent upwards during the fall.

LPA Marrufo interviewed staff S1, who stated that R2 become argumentative with S1 at the medication room when R2 refused to take medications.

See LIC9099-C for more information. Page 1 of 2.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022

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-20220506153158

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 # 1	FACILITY NUMBER: 430700017
	VISIT DATE: 05/12/2022

NARRATIVE

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S1 stated that R2 then pushed S1, and then S1 grabbed R2 by the shoulders and pushed R2 down onto the ground of the balcony by the medication room. S1 stated to have put his/her knees on R2's back and told R2 to calm down. S1 stated to have put his/her knee on R2's back for around 10 seconds. S1 stated to prefer that the residents have altercations with S1 than with the other staff.

During interview, resident R9 stated to have witnessed the incident while sitting in the court yard next to the medication room. R9 stated to have observed R2 and S1 arguing and yelling at each other at the medication room, and observed S1 approach R2 from the doorway of the medication room and push R2 down onto the ground of the balcony near the medication room. R9 stated R2 landed on his/her back near the trash can that is near the window of the medication room.

Residents R3-R8 stated to have not observed any staff push a resident. Staff S3-S5 stated to have not observed any staff push a resident. Staff S2 stated during interview to have observed R2 push S1, and then S1 pivoted and pushed R2 up against the wall of the medication room. S2 stated that then R2 slipped underneath S1's arms and ran away.

LPA Marrufo interviewed Designated Administrator Renee Sabankaya, who stated to have not observed or heard about any incident involving a staff pushing a resident.

Deficiencies were cited as per California Code of Regulations Title 22. See LIC9099-D for more information.

This report was reviewed with Renee Sabankaya and a copy of the report was provided.

Page 2 of 2.

SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20220506153158

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 # 1	FACILITY NUMBER: 430700017
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/12/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/13/2022 Section Cited CCR 80072(a)(3)	1 2 3 4 5 6 7	80072(a)(3) Personal RIghts: Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse,	1 2 3 4 5 6 7	Licensee agrees to submit a plan to conduct training for all staff on how to respect the personal rights of residents by POC date. Once training is completed, Licensee shall submit a record of staff training that includes date of training(s), names and signatures of staff trained, training topics, and name and
	8 9 10 11 12 13 14	or other actions of a punitive nature...This requirement was not met as evidenced by: Licensee did not ensure that staff S1 did not push R2 onto the ground and put his/her knee on R2's back, which is an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	qualification of trainers to CCL.
Type A 05/13/2022 Section Cited HSC 1558(a)(2)	1 2 3 4 5 6 7	1558(a)(2) Persons prohibited from employment; dismissal or removal; appeal: a) The department may prohibit any person from being a member of the board of directors, an executive director, or an officer of a licensee, or a licensee from employing, or continuing the	1 2 3 4 5 6 7	Licensee agrees to submit a plan to conduct training for all staff on how to interact with residents by POC date. Once training is completed, Licensee shall submit a record of staff training that includes date of training(s), names and signatures of staff trained, training topics, and name and
	8 9 10 11 12 13 14	employment of, or allowing in a licensed facility or certified family home, or allowing contact with clients of a licensed facility or certified family home by, any employee, prospective employee, or person who is not a client who has: Engaged in conduct that is inimical to the health, morals, welfare, or safety of either the people of this state or an individual in, or receiving services from, the facility or certified family home.	8 9 10 11 12 13 14	qualification of trainers to CCL.

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: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022

LIC9099 (FAS) - (06/04)

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