430700017-6-25-2026-26-AS-MYAZ-DVDVWC-20260625164744

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 430700017
Report Date: 06/25/2026
Date Signed: 06/25/2026 04:48:00 PM

Document Has Been Signed on 06/25/2026 04:48 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 # 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:	06/25/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:30 AM
MET WITH:	Prunella Cardozo		TIME VISIT/ INSPECTION COMPLETED:	05:00 PM

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	Licensing Program Analyst (LPA) Marcela Yanez conducted an unannounced Required 1 Year visit and met with Prunella Cardozo, Administrator. LPA announced the purpose of the visit. During visit, LPA toured the facility inside and out. LPA observed the kitchen area and observed sharps locked in the freezer, cleaning supplies are locked in the housekeeping closet. LPA observed perishable food supply of at least two days and a non-perishable food supply of at least seven days. Freezer temperature measured with thermometer at -2 degrees to -1 degrees F. LPA toured resident bedrooms. Each bedroom had available bedding and clothing storage areas as well as functioning lights. The carbon monoxide/smoke detector is connected to the pull fire alarm. LPA toured resident bathroom. Bathroom had available soap and paper towels and functioning lights. The water temperatures in the bathroom sinks measured with thermometer at 133 degrees F at 9:09 AM and did not regulate in the main building. The water temperature in the laredo house bathroom measured at 114.6 degrees F. at 3:13 pm. During tour LPA observed the window blinds in disrepair in rooms 3,4,5,6 and missing screen in bedroom 6 in main building and in laredo house room 10. LPA observed in desrepair screen with a 1 inch x 1 inch hole in rooms 12 and 14. LPA toured the outside area and found the exits to be clear of obstructions. LPA observed fire extinguisher was last serviced on 08/14/25. LPA reviewed Fire and Earthquake log, Last disaster drill conducted on 03/18/26. LPA reviewed resident records for 5 residents and Centrally stored medication. ADM stated residents file reviewed manage their own money. Deficiency were cited as per California Code of Regulations Title 22, and technical violation was also issued. This report was reviewed with ADM and a copy of this report and appeal rights were provided

NAME OF LICENSING PROGRAM MANAGER: Christine Kabariti
NAME OF LICENSING PROGRAM ANALYST: Marcela Yanez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/25/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2026

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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Document Has Been Signed on 06/25/2026 04:48 PM - It Cannot Be Edited

Created By: Marcela Yanez On 06/25/2026 at 03:57 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: 06/25/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80088(e)(1)

Fixtures, Furniture, Equipment, and Supplies

(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above by having the water temperature measure at 133 degrees f in main buliding and 123 in laredo house which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/26/2026
	Plan of Correction
1 2 3 4	ADM stated the water temperature will be regulated and submit proof of correction picture to LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 06/25/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2026

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 06/25/2026 04:48 PM - It Cannot Be Edited

Created By: Marcela Yanez On 06/25/2026 at 03:57 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: 06/25/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80088(b)

Fixtures, Furniture, Equipment, and Supplies

(b) All window screens shall be in good repair and be free of insects, dirt and other debris. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation , the licensee did not comply with the section cited above bedroom #6 and hallway window screen near stairs did not have a window screen in which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/06/2026
	Plan of Correction
1 2 3 4	ADM stated the facility will replace window screen and send proof of correction picture via email to LPA by POC due date

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 06/25/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2026

LIC809 (FAS) - (06/04)

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