430700017-1-23-2026-26-AS-MYAZ-DQLNP4-20260123093744

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 430700017
Report Date: 01/23/2026
Date Signed: 01/23/2026 09:38:02 AM

Document Has Been Signed on 01/23/2026 09:38 AM - 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 # 1		FACILITY NUMBER:	430700017
ADMINISTRATOR/ DIRECTOR:	PRUNELLA CARDOZO		FACILITY TYPE:	735
ADDRESS:	260 SOUTH 11TH STREET		TELEPHONE:	(408) 289-1644
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95112
CAPACITY: 38		CENSUS: 35	DATE:	01/23/2026
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:15 AM
MET WITH:	Frank Ebo		TIME VISIT/ INSPECTION COMPLETED:	09:45 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 01/23/26 Marcela Yanez conducted an unannounced case management visit to deliver findings on an investigation. LPA announced the purpose of the visit and met with Frank Ebo, Designated Administrator. Administrator was reached by phone regarding visit. On July 17, 2025, the department received an incident report regarding an altercation between a previous client and a current client that occurred on July 16,2025. During the investigation the department interviewed 4 staff and 2 clients. S1 stated that during his/her shift a previous client (C3) arrived at the facility and was agitated and began fighting with 2 current clients (C1 and C2). S1 who was in the medication room of the facility, and the only staff on shift, was watching the monitors that display video surveillance of the facility premises and observed C3 arrive at the facility. S1 stated he/she asked C3 to leave the facility C3 left but then returned on 2 different occasions the same night of incident but returned a third time. C3 left the facility but shortly returned at 7:58 PM. C3 was observed walking towards the client’s bedroom. S1 called local law enforcement and was on the phone with dispatch when he/she saw C3 attack C2 in the hallway. S1 remained in the medication room on the phone with local law enforcement while C2 was being attacked. After C3 attacked C2, C3 walked to the courtyard and attacked C1. S1 stated that he/she observed the resident being attacked through the enclosed medication room window which faces the courtyard S1 stayed in the locked medication room during the whole incident until C3 left the facility. Page 1 of 3

NAME OF LICENSING PROGRAM MANAGER: Christine Kabariti
NAME OF LICENSING PROGRAM ANALYST: Marcela Yanez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/23/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 # 1	FACILITY NUMBER: 430700017
	VISIT DATE: 01/23/2026

NARRATIVE

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S1, S2, S3 and S4 stated the facility is not allowed to touch the clients during an altercation but is encouraged to try to stop the altercation verbally. S1 During the altercation was observed to not have attempted to interrupt the fight or give aid to C1 and C2. S1 stated he/she closed the medication room door and locked it. S1 stated he/she yelled at C3 through the window when he/she was on the phone with local law enforcement after the altercation C3 left the facility prior to local law enforcement arrival. Based on the 911 call, S1 did not attempt to intervene to stop the altercation from continuing.

S2 and S3 stated that C3 had been evicted from the facility for a previous altercation but could not provide a date. S2 and S3 also stated that C3 had aggressive and bullying behavior and would always bully other clients into giving him/her their money. On July 17, 2025, S2 sent C1 back to the hospital after seeing C1 in bad shape.

S3 stated that that C3 had never attacked any residents after he/she had been evicted. S3 also stated that the facility staff are instructed to call each other on their cell phone when they need help. S3 stated that S1 had called S4 regarding C3 coming to the facility but had left at the time S1 spoke to S4. S3 stated that the caretaker was normally on site but on that date he/she was not at the facility.

S4 stated that he/she was working at the sister facility when incident occurred and was supposed to be shadowing S1 but was not sure why he/she was scheduled at the sister facility. S4 stated he/she had been working for 2 months. S4 stated he/she was not aware why he/she was being interviewed since he/she was not present when the incident occurred. S4 stated that S1 had called and told him/her that C3 had showed up at the facility and was destroying plants and he/she was going to call 911 to have C3 arrested.

S4 stated that he/she later heard that C3 had attacked a few clients and was going to go to the facility but did not because S1 stated he/she was ok. S4 stated he/she had never met C3 but was aware of the frequent visits to facility to steal from clients.

NAME OF LICENSING PROGRAM MANAGER: Christine Kabariti
NAME OF LICENSING PROGRAM ANALYST: Marcela Yanez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/23/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2026

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 # 1	FACILITY NUMBER: 430700017
	VISIT DATE: 01/23/2026

NARRATIVE

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S1, S2 and S3 stated that the facility normally schedules 2 staff on each shift, to include the swing shift. Based on interviews, S1 was the only staff working at the facility the night of the incident.

As a result of the incident on January 16, 2025, C2 sustained minor injuries to the face. (C1) was sent to the hospital with extensive bruising, scrapes, and diagnosed with a nasal bone fracture.

The Department has concluded its investigation. Deficiencies being cited per California code of regulation Title 22 see LIC809-D.

An immediate civil penalty of $1000 is being assessed against the facility today for repeat violation within the 12 month period in which staff did not provide care and supervision during a client on client altercation resulting in C1 sustaining a serious injury. An additional civil penalty will be pending review. See LIC421-IM.

This report was reviewed with Frank Ebo, Designated Administrator a copy of the report and appeals rights were provided

NAME OF LICENSING PROGRAM MANAGER: Christine Kabariti
NAME OF LICENSING PROGRAM ANALYST: Marcela Yanez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/23/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/23/2026 09:38 AM - It Cannot Be Edited

Created By: Marcela Yanez On 01/23/2026 at 08:36 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: 01/23/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/24/2026 Section Cited CCR 80065(a)	1 2 3 4 5 6 7	(a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	ADM stated he/she will submit a letter of understanding of regulation and a plan of action on how he/she will ensure staff is trained in how to handle altercations. ADM will submit by POC 01/24/26
	8 9 10 11 12 13 14	Based on record review and interviews conducted the licensee did not comply with the section cited above wherein staff (S1) who was the only staff at the facility did not attempt to intervene and stop C3 from attacking C1and C2, resulting in C1 sustaining serious injury which poses an immediate health and safety and personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Christine Kabariti
NAME OF LICENSING PROGRAM MANAGER:

	Marcela Yanez
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/23/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2026

LIC809 (FAS) - (06/04)

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