430700017-10-29-2025-26-AS-ACON-DNJ239-20251117160158

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 430700017
Report Date: 10/29/2025
Date Signed: 10/29/2025 09:45:47 AM

Unsubstantiated

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
07/29/2025 and conducted by Evaluator Marcela Yanez

COMPLAINT CONTROL NUMBER: 26-AS-20250729115256

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: 32	DATE:	10/29/2025
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Prunella Cardozo, Administrator		TIME COMPLETED:	09:55 AM

ALLEGATION(S):

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Resident was not allowed return to facility after hospitalization
Facility abandoned resident at hospital.

INVESTIGATION FINDINGS:

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On 10/29/25 Licensing Program Analyst Marcela Yanez conducted an unannounced complaint investigation visit to deliver findings and met with Prunella Cardozo, Administrator. LPA announced the purpose of the visit.

On 07/29/25 the department received a complaint with the above allegations.

On 08/04/25 Licensing Program Analyst (LPA) Marcela Yanez conducted an initial 10-day complaint visit and met with Prunella Cardozo, Administrator. LPA interviewed 2 staff, and obtained pertinent documents, Physicians report, after visit summary, Appraisal Needs and Services, email communication, resident notes and daily logs.

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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE:	DATE: 10/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20250729115256

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: 10/29/2025

NARRATIVE

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During the investigation the department interviewed Administrator (ADM), Staff (S1), Witness (W1) and Witness (W2). ADM stated that R1 had gone to the Hospital on 07/16/25 due to an altercation between him/her and a previous Resident (R2). ADM stated that R1 suffered serious injuries. Medical documentation stated the resident had significant hearing and vision loss from the incident.

On 07/17/25 R1 was returned to the facility at the doorstep and EMT did not notify any staff when they dropped off R1. R1 was observed by NOC shift through the facility Camera waiting at the facility entrance to be let in.

On 07/17/25 the facility staff noticed R1 was having difficulty maintaining his/her gait and had removed his/her bandages. ADM called the ambulance to have R1 returned to the hospital because of his/her injuries. When R1 was ready to be released ADM stated resident still needed a higher level of care because of his/her vision loss and that the resident had been having difficulty walking and tripping prior to the incident on 07/16/25.

On 04/10/25 R1 suffered a fall while waiting for his/her morning medication due to unsteady gate, at that time the facility began email communication between R1s Case Manager (CM) at Community Solutions asking for R1 to be seen by a doctor and are asking CM to be present at the doctor’s appointment.

On 05/19/25 the facility received an email from Community Solutions Admin/Support that the R1 was scheduled for an appointment on 05/27/25. Admin/Support stated that since the Case Manager has been scheduling R1s doctors’ appointment then if CM is able to attend, they will confirm the appointment. CM never made the appointment for R1.

On 07/01/25 an email from S1 to CM stating that R1s vision has been getting worse and has been needing more help with Activities of Daily Living (ADL) and requesting an updated functional capability assessment and a new physicians report was needed.

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE:	DATE: 10/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2025

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20250729115256

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: 10/29/2025

NARRATIVE

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On 07/25/25 R1 was ready to be released from Valley Medical Center, after the altercation on 07/16/25, back to the facility. ADM informed W1 that R1 needed to be assessed before returning to the facility. ADM had several discussions with W1 regarding R1s capability to return to the facility and that the facility stated he/she needed a higher level of care. W1 stated that the resident was referred to the bronze team at valley medical to be placed back to the community or for placement. ADM stated that the Case Manager was informed that the facility has concerns for R1s safety and needs to have a new functional capability test and that the facility states resident needs a higher level of care. ADM was scheduled to visit R1 in the hospital prior to his/her discharge and when ADM called W1 to ask what the room number and floor R1 was on was informed not to come to reassess that Resident was revaluated discharge planning team with Social Worker and Doctors and CM decided resident needed higher level of care and resident was sent to a Skilled nursing Facility.

On 08/21/25 the facility ADM received a call from the Skilled Nursing Facility stating R1 was rehabilitated and can return to the facility. ADM informed W2 that R1 needed to be assessed prior to returning to the facility. ADM visited R1 at the Skilled Nursing Facility and stated to W1 that R1 needed a higher level of care. W1 stated that R1 was frequently reminded to use auditory device to be able to hear and continued to not wear his/her eyeglasses. ADM stated the facility believed that R1 would be safer at a facility that can provide higher level of care. W1 stated the R1 was placed at board and Care Home where resident is thriving.

On 10/14/25 the department concluded its investigation.

Based on investigation, interviews conducted, and records reviewed, the Department found that the above allegation is UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur.

This report was reviewed with Administrator, Prunella Cardozo, and a copy of the report was provided.

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2025

LIC9099 (FAS) - (06/04)

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