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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430700017
Report Date: 04/06/2023
Date Signed: 04/06/2023 12:05:20 PM

Document Has Been Signed on 04/06/2023 12:05 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:
04/06/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:TIME COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a Plan of Correction (POC) visit due to a POC that has not been submitted. LPA met with Licensee, Mustafa Sabankaya.

On 02/23/2023, the facility was issued a deficiency regarding incomplete records for residents needs and services plan. Part of the facility’s plan of correction (POC) was to submit a written plan and procedure to ensure current and new residents will have a written needs and services plan on file. Per request of the facility, the POC was extended until 04/01/2023.

On 03/30/2023, LPA Dolores received a call from the designated Administrator and during the call LPA provided a courtesy reminder of the POC due. Designated Administrator understood their POC was approaching and verbalized their plan of action. Designated Administrator was informed to send their plan and procedures in writing.

On 04/01/2023, the Department did not receive the facility’s plan of correction. On 04/03/2023, LPA followed-up with the Licensee and designated Administrator regarding the POC. On 04/05/2023, LPA received a response but still did not receive the POC.

A deficiency is being cited per California Code of Regulations, Title 22. See LIC809-D.

Exit interview was conducted with Licensee, Mustafa Sabankaya and a copy of the report was provided along with the appeal rights.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/06/2023
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 04/06/2023 12:05 PM - It Cannot Be Edited


Created By: Christine Dolores On 04/06/2023 at 09:36 AM
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: 04/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/14/2023
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 submit their written plan and procedure to ensure current and new residents will have a written needs and services plan on file.
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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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Licensee will send POC via email to LPA 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: 04/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2023


LIC809 (FAS) - (06/04)
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