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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430700017
Report Date: 07/27/2023
Date Signed: 07/27/2023 06:27:56 PM


Document Has Been Signed on 07/27/2023 06:27 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
CENTRAL COAST CR/RES, 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: DATE:
07/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Maria CanizalesTIME COMPLETED:
06:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Christine Dolores and Grace Donato arrived unannounced to conduct the facility’s required 1 year annual inspection. LPAs met with Program Director (PD) Maria Canizales. This facility's annual inspection was combined with Ali Baba #2. Due to technical difficulties, the facility's visit was written as a case management - other visit.

During visit, LPAs toured the facility to include the resident bedrooms, bathrooms, medication room, dining room, kitchen, basement and exterior. All staff members present are fingerprint cleared and associated to the facility.

Fire extinguishers last serviced on 11/08/2022. The facility has at least one operating carbon monoxide detector present in each building.

The resident’s bathroom located in the hallway of Laredo House hot water temperature maintained at 90 degrees Fahrenheit. The water pressure in the bathroom observed very low with little streams of water. PD states the water pressure is on the list of items to service for the maintenance personnel. The bathrooms observed with hygiene supplies and paper supplies. Resident bedrooms all contain beds, linens, adequate lighting, dresser, and night stand. Bedrooms observed well maintained. Bedroom #2 located in the Main House hot water temperature maintained at 110 degrees Fahrenheit.

The facility’s kitchen contained perishables and non-perishable foods. Items inside the refrigerator was observed covered. The facility has clean utensils, plates, bowls and cups. The facility’s basement contained 4 freezers Freezer #1 temperature maintained at 20 degrees Fahrenheit. Freezer #2 temperature maintained at 0 degrees Fahrenheit. Freezer #2 observed with deceased bugs and food particles located at the bottom of the freezer. 2 out of 4 freezers did not contain a thermometer. The basement contained additional non-perishable food. Based on interview, the facility does not have an emergency food supply in case of an emergency. SEE LIC809-C.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
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.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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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The basement’s fire extinguishers were last serviced in 11/2019.

LPAs reviewed resident (R1 – R5’s) records to include centrally stored medication record, personal rights, admission agreement, physician’s report, functional capabilities assessment, appraisal needs and services plan, safeguard of personal property form, and safeguard of cash resources. LPA observed resident (R1)’s file did not contain an appraisal needs and services plan and R2’s appraisal needs and services plan was last updated in 2017.

LPAs entered facility Club Riviera to review the facility’s personnel files and resident cash resources. LPAs observed the facility commingles resident’s cash resources with facility Ali Baba #1, Ali Baba #2, and Club Riviera.

LPAs reviewed 6 staff (S1 – S6’s) records to include 1st Aid certification, job application, health screening, criminal record statement, employee rights, and TB test. 5 out of 6 staff members does not obtain a 1st Aid certification. 6 out of 6 staff does not have a health screening report completed. Based on interview and record review, facility staff were not provided fire and emergency drills.

5 residents were interviewed.

Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Program Director, Maria Canizales and a copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
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
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 07/27/2023 06:27 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
80075(f)

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(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross. This requirement is not met as evidenced by:
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Licensee will send their plan to complete 1st Aid Certification. Licensee will send LPA Dolores the written plan by POC by due date.
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Based on observation, interview, and record review the licensee did not ensure staff obtain a first aid certification which poses an immediate health, safety, and personal rights risk to person in care.
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Type A
07/28/2023
Section Cited
CCR80076(a)(17)

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(a) In facilities providing meals to clients, the following shall apply: (17) All kitchen, food preparation, and storage areas shall be kept clean, free of litter and rubbish, and measures shall be taken to keep all such areas free of rodents, and other vermin. This requirement is not met as evidenced by:
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Licensee will clean the freezer by 07/28/2023. Licensee will submit a picture of the freezer by POC due date.
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Based on observation and interview the licensee did not ensure to keep the freezer free from deceased insects and food particles which posed 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.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
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
LIC809 (FAS) - (06/04)
Page: 3 of 6


Document Has Been Signed on 07/27/2023 06:27 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
80088(e)(1)

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(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement is not met as evidenced by:
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Licensee will adjust the hot water temperature by POC due date. Licensee will submit a picture of the water temperature to LPA Dolores by POC due date.
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Based on observation the facility's hot water temperature in Laredo House was maintained at 90 degrees Fahreinheit which posed an immediate health, safety, and personal rights risk to persons in care.
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Type A
07/28/2023
Section Cited
CCR85076(d)(2)

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(2) Freezers shall be large enough to accommodate required perishables and shall be maintained at a temperature of zero degrees F (-17.7 degrees C). This requirement is not met as evidenced by:
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Licensee will purchase a thermometer for 2 out of 4 freezers. Licensee will submit a picture of Freezer #1's temperature. Licensee will submit a photo of both items to LPA by POC due date.
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Based on observation the facility's freezer #1's temperature maintained at 20 degrees Fahreinheit and 2 out of 4 freezer's did not contain a thermometer 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.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
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
LIC809 (FAS) - (06/04)
Page: 4 of 6


Document Has Been Signed on 07/27/2023 06:27 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 B
08/03/2023
Section Cited
CCR
80066(a)(10)

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(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g). This requirement is not met as evidenced by:
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Licensee will submit a written plan to ensure staff are provided health screenings. Licensee will submit the plan to LPA by POC due date.
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Based on observation, interview and record review the licensee did not ensure 6 out of 6 staff completed a health screening by a physician which poses a potential health, safety, and personal rights risk to persons in care.
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Type B
08/15/2023
Section Cited
CCR85068.3(a)

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(a) The written Needs and Services Plan specified in Section 85068.2 shall be updated as frequently as necessary to ensure its accuracy, and to document significant occurrences that result in changes in the client's physical, mental and/or social functioning. This requirement is not met as evidenced by:
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Licensee will ensure residents will have a needs and services on file by August 15, 2023. Licensee will submit a list of all resident's names and when the needs and services plan was completed by POC due date.
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Based on observation, interview, and record review the licensee did not ensure resident's files contain an appraisal needs and services plan and R2’s appraisal needs and services plan was last updated in 2017.
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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.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
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
LIC809 (FAS) - (06/04)
Page: 5 of 6


Document Has Been Signed on 07/27/2023 06:27 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 B
08/10/2023
Section Cited
CCR
1565(c)

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(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill. This requirement is not met as evidenced by:
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Licensee will conduct their first emergency drill within 2 weeks. Licensee will submit the drill documentation to LPA by POC due date.
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Based on observation, interview, and record review the licensee did not ensure to conduct a drill at least quarterly with staff which poses a potential health, safety, and personal rights risk to persons in care.
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Type B
08/04/2023
Section Cited
CCR80026(g)

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(g) The licensee shall not commingle cash resources and valuables of clients with those of another community care facility of a different license number regardless of joint ownership. This requirement is not met as evidenced by:
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Licensee will submit a picture of how they plan to separate the facility's residents cash resources to LPA by POC due date.
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Based on interview, record review, and observation the residents cash resources were being commingled with Ali Baba #1, Ali Baba #2, and Club Riviera which poses a potential 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.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
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
LIC809 (FAS) - (06/04)
Page: 6 of 6