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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430700017
Report Date: 02/23/2023
Date Signed: 02/23/2023 02:59:26 PM

Document Has Been Signed on 02/23/2023 02:59 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: 35DATE:
02/23/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Renee SabankayaTIME COMPLETED:
03:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Dolores arrived to the facility unannounced to open complaint investigations. During visit, LPA observed violations and conducted a case management - deficiencies visit. LPA met with Case Manager (CM), Susana Tovar, General Manager (GM), Elaine Sabankaya, and Designated Administrator, Renee Sabankaya.

During visit, LPA requested for residents (R1 - R2) appraisal needs and services plan. The facility was unable to provide the requested documents. Staff states the facility did not develop a needs and services plan for R1 - R2 prior to Admission. Staff state not all clients has a needs and services plan.

LPA asked of the facility's procedures for when a resident is observed to have a change of condition. For any change of condition, the details are written in the resident's progress notes and communicated with the appropriate parties. The residents needs and services plans are also not being updated when there is any change of condition/behavior. During visit, LPA advised the designated Administrator, CM, and GM. All 3 individuals stated understanding.

A deficiency was cited per California Code of Regulations, Title 22. See LIC809D.

This report was reviewed with designated Administrator, Renee Sabankaya and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2023
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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Document Has Been Signed on 02/23/2023 02:59 PM - It Cannot Be Edited


Created By: Christine Dolores On 02/23/2023 at 01:15 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: 02/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/02/2023
Section Cited
CCR
80068.2(a)

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(a) The licensee shall complete a Needs and Services Plan for each client as required in Sections 81068.2, 82068.2, 82568.2, or 85068.2. This requirement is not met as evidence by:
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Licensee will ensure all residents will have a needs and services plan on file. Licensee will review sections 80068.2, 85068.2, and 85068.3 and send a statement of understanding of the sections. Licensee will train appropriate staff on these sections and send the Department
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Based on interview, record review, and observation the facility does not maintain a needs and services plan for all the residents prior to admission and upon a change in condition which poses a potential health, safety, and personal rights risk to persons in care.
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a written plan and procedure to ensure current and new residents will have a written needs and services plan on file. Licensee will send POC via email by POC due date.

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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 Yip
LICENSING EVALUATOR NAME:Christine Dolores
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2023


LIC809 (FAS) - (06/04)
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