Community Care Licensing

Document Has Been Signed on 07/08/2022 12:27 PM - It Cannot Be Edited

FACILITY NAME:	ALI BABA # 1		FACILITY NUMBER:	430700017
ADMINISTRATOR:	CHERALYNN SABANKAYA		FACILITY TYPE:	735
ADDRESS:	260 SOUTH 11TH STREET		TELEPHONE:	(408) 289-1644
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95112
CAPACITY: 38		CENSUS: 29	DATE:	07/08/2022
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME BEGAN:	11:38 AM
MET WITH:	Renee Sabankaya		TIME COMPLETED:	12:30 PM

SUPERVISORS NAME: Sarah Yip LICENSING EVALUATOR NAME: David Marrufo LICENSING EVALUATOR SIGNATURE: DATE: 07/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/08/2022

Link to Parent Document Below:

FACILITY NAME: ALI BABA # 1	FACILITY NUMBER: 430700017
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/08/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/09/2022 Section Cited CCR 80087(a)	1 2 3 4 5 6 7	80072(a)(3) Personal RIghts: Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse,	1 2 3 4 5 6 7	Licensee agrees to submit a plan to conduct training for all staff on how to respect the personal rights of residents by POC date. Once training is completed, Licensee shall submit a record of staff training that includes date of training(s), names and signatures of staff trained, training topics, and name and
	8 9 10 11 12 13 14	or other actions of a punitive nature...This requirement was not met as evidenced by: Licensee did not ensure that staff S1 did not push R2 onto the ground and put his/her knee on R2's back, which is an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	qualification of trainers to CCL.
Type A 07/09/2022 Section Cited CCR1558(a)(2)	1 2 3 4 5 6 7	1558(a)(2) Persons prohibited from employment; dismissal or removal; appeal: a) The department may prohibit any person from being a member of the board of directors, an executive director, or an officer of a licensee, or a licensee from employing, or continuing the	1 2 3 4 5 6 7	Licensee agrees to submit a plan to conduct training for all staff on how to interact with residents by POC date. Once training is completed, Licensee shall submit a record of staff training that includes date of training(s), names and signatures of staff trained,
	8 9 10 11 12 13 14	employment of, or allowing in a licensed facility or certified family home, or allowing contact with clients of a licensed facility or certified family home by, any employee, prospective employee, or person who is not a client who has: Engaged in conduct that is inimical to the health, morals, welfare, or safety of either the people of this state or an individual in, or receiving services from, the facility or certified family home.	8 9 10 11 12 13 14	qualification of trainers to CCL.

SUPERVISOR'S NAME: Sarah Yip LICENSING EVALUATOR NAME: David Marrufo LICENSING EVALUATOR SIGNATURE: DATE: 07/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/08/2022

Link to Parent Document Below:

FACILITY NAME: ALI BABA # 1	FACILITY NUMBER: 430700017
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/08/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/15/2022 Section Cited CCR 80087(a)	1 2 3 4 5 6 7	80087(a) Buildings and Grounds: (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This regulation was not met as evidenced by: Licensee did not ensure that each resident	1 2 3 4 5 6 7	Licensee agrees to replace all missing window screens, repair the holes in the exteriors of Buildings 2 and 3, remove debris from the gutters, and repair the two light fixtures with missing covers by POC date. Licensee shall submit photographic proof of
	8 9 10 11 12 13 14	bedroom has window screens installed, that the facility exterior walls do not have holes, that the gutters are kept free of obstructions, and that light fixtures are repaired, which poses a potential safety risk to residents in care.	8 9 10 11 12 13 14	all repairs by POC date.
	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

SUPERVISOR'S NAME: Sarah Yip LICENSING EVALUATOR NAME: David Marrufo LICENSING EVALUATOR SIGNATURE: DATE: 07/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/08/2022