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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 12:07:14 PM

Document Has Been Signed on 04/06/2023 12:07 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:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Mustafa SabankayaTIME COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management - other visit. LPA met with Licensee, Mustafa Sabankaya. The purpose of the visit is to issue a civil penalty regarding a staff working in the facility without obtaining a criminal record clearance or criminal record exemption prior to starting work.

On 03/23/2023, the Department received a letter from Care Provider Management Bureau (CPMB) of a prospective employee (S1) criminal record exemption needed letter that was returned to the Department due to an incorrect facility mailing address. On 03/24/2023, LPA Dolores emailed the facility manager and Licensee the CPMB document. Upon a telephone call from the facility, it was found the individual (S1) was working with residents in the facility from October 2022 – December 2022 without obtaining a criminal record clearance / exemption. Based record review, the individual completed a live scan on 09/13/2022. The Licensee did not receive a criminal background clearance letter from the Department prior to the individual starting work. The individual’s last day at the facility was in November 7, 2022.

Documents were obtained to include S1's live scan form and timecard from October 2022 - November 2022.

A deficiency is being cited per California Code of Regulations, Title 22. See LIC809-D. A civil penalty is being assessed for the amount of $500 ($100 per day x 5 days = $500) for staff (S1) working at the facility without fingerprint clearance. See LIC421BG.

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 12:07 PM - It Cannot Be Edited


Created By: Christine Dolores On 04/06/2023 at 09:32 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 A
04/07/2023
Section Cited
CCR
80019(e)(1)

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(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or… This requirement is not met as evidenced by:
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Licensee will review section 80019 and submit a statement of understanding to LPA via email by POC due date.
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Based on interview and record review, the Licensee did not ensure S1 obtained a criminal record clearance or criminal record exemption prior to S1 working in the facility which poses an immediate health, safety, and personal rights risk to persons in care.
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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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