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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430700017
Report Date: 10/27/2021
Date Signed: 10/27/2021 01:48:44 PM

Document Has Been Signed on 10/27/2021 01:48 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: DATE:
10/27/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:TIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced visit to the facility as part of a complaint investigation and met with Renee Sabankaya.

While at the facility, LPA Marrufo observed there to be two gasoline containers left unsecured near the stairway of the Palm Villa facility building. The two gasoline containers were roughly three feet away from a table in the facility smoking area. LPA Marrufo observed residents smoking at that table upon arriving at the facility. The two gasoline containers were each about one third full with fluid. Facility staff S1 stated that the gasoline containers were filled with a mixture of oil and gasoline.

LPA Marrufo interviewed staff S1, and S1 stated that someone must have forgotten to return the gasoline containers back to the storage area.

LPA Marrufo advised Designated Administrator Renee Sabankaya of the importance of securing chemicals, especially flammable chemicals, at the facility. The two gasoline containers were secured behind a locked gate during visit.

A deficiency was cited as per California Code of Regulations Title 22. See LIC809-D for more information.

This report was reviewed with Renee Sabankaya and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2021
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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Document Has Been Signed on 10/27/2021 01:48 PM - It Cannot Be Edited


Created By: David Marrufo On 10/27/2021 at 12:34 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 10/27/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/28/2021
Section Cited
CCR
80087(g)

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(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement was
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Licensee agrees to properly secure all gasoline containers and any container containing hazardous materials in locked storage.
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not met as evidenced by: Licensee did not ensure that two gasoline containers were not properly secured at the facility, which poses an immediate safety risk to residents in care.
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***Deficiency Cleared During Visit***

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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:Jackie Jin
LICENSING EVALUATOR NAME:David Marrufo
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2021


LIC809 (FAS) - (06/04)
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