430700017-5-26-2022-26-AS-KHOS-CRFHHF-20230502061241

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 430700017
Report Date: 05/26/2022
Date Signed: 05/26/2022 05:09:07 PM

Unsubstantiated

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
05/19/2022 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20220519111222

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: 30	DATE:	05/26/2022
		UNANNOUNCED	TIME BEGAN:	04:30 PM
MET WITH:	Renee Sabankaya		TIME COMPLETED:	05:10 PM

ALLEGATION(S):

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Unlawful eviction

INVESTIGATION FINDINGS:

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

LPA Marrufo determined that the above allegation is in regards to the same resident and incident that were included as an allegation that was part of a complaint against the facility dated 10/09/2020. That allegation was found to be unsubstantiated. LPA Marrufo conducted complaint visits to the facility as part of that investigation on 10/19/2020 and 05/06/2021 and conducted additional interviews and records reviews on additional dates. LPA Marrufo obtained the following information as part of the complaint investigation:

6 out of the 7 interviewed residents stated to have not observed staff illegally evict a resident. 1 out of the 7 residents refused to answer the question. 5 out of the 8 staff stated to have not observed staff illegally evict a resident. 2 out of the 8 staff refused to answer the question. See LIC9099-C for more information.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022

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-20220519111222

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: 05/26/2022

NARRATIVE

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1 out of the 8 staff stated to have told resident R1 that R1 needed to take a COVID-19 test or R1 would not be able to live at the facility, although R1 was never issued a formal eviction notice. 1 out of 2 witnesses stated that R1 was evicted from the facility. 1 out of 2 witnesses stated that a resident was given notification from the facility that placement agencies would be moving the resident along with 20 other residents out of the facility.

The LIC624 Incident Report filed on 11/09/2020 states that on 08/07/2020, staff told R1 that R1 needed to take a COVID-19 test to stay at the facility and then R1 left the facility with a large trash bag containing R1’s belongings.

The facility Daily Log from 08/07/2020 also states that facility staff told R1 that R1 was required to take a COVID-19 test to stay at the facility and R1 responded by leaving the facility with a large trash bag of R1’s belongings.

The San Jose Police Department Missing Person Report states that R1 left the facility with a large trash bag of belongings after refusing to take a COVID-19 test.

Based on information from interviews conducted with staff and residents, and records reviewed, although the allegation listed above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

No Deficiencies cited at this time under 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: 05/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022

LIC9099 (FAS) - (06/04)

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