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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 430700017
Report Date: 07/27/2023
Date Signed: 07/28/2023 10:55:32 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/04/2020 and conducted by Evaluator Simranjit Rai
COMPLAINT CONTROL NUMBER: 26-AS-20200804115831
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:
07/27/2023
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator Maria CanizalTIME COMPLETED:
07:00 PM
ALLEGATION(S):
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Staff are not administering medications to resident as prescribed by their physician.
Facility does not contact resident's responsible party when resident is seeking medical services.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Simi Rai and Manuel Monter and Licensing Program Manager (LPM) Romeo Manzano conducted an unannounced inspection/investigation visit to conclude and deliver investigation of the above allegations. LPAs and LPM met with Administrator Maria Canizal and stated the purpose of today's visit.

On 8/4/2020, the Department received a complaint with the above allegations.

Continuation, LIC 9099-C.
Page 1 of 3.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 26-AS-20200804115831
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/27/2023
NARRATIVE
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Page 2 of 3.
Staff are not administering medications to resident as prescribed by their physician.

On 08/14/2020, the Department conducted an initial invesigation/inspection of the above allegations that staff did not wake up R1 for his/her AM (morning) medications resulted in missing his/her medication. The Reporting Party (RP) alleged that staff are aware that R1 sleeps deeply, and none of the staff had waken her/him up for medication and R1's responsible party was not notified of R1's fall incident and hospitalization.
During this initial visit, the facility Administrator (ADM) was interviewed, ADM stated that the facility staff are aware of a written policy by reminding residents of their medication to check-in with staff at least 2-3 times, in the medication room. ADM stated if a resident ignore the reminder and choose to sleep through; staff will note "M" for missed on their medication administration records (MARs) sheet to indicate that he/she missed his/her medications. ADM denied that staff are refusing to assist residents with their medications.
On 08/17/2020, the Department conducted an interview with R1's social worker (SW). SW stated that he/she was aware that staff had a hard time waking R1's up for his/her morning medication due to sleeping disorder. SW stated that facility staff had agreed that staff would go and get him/her up within 15 minutes, staff would try to wake him/her up. SW stated that when staff started implementing what they agreed upon, it improved but then he/she does not know what happened why R1 had missed his/her medications.

On 09/01/2020, the Department conducted an interview with R1's case manager (CM). CM stated he/she is aware that R1 overslept a lot. CM stated he/she have heard mixed stories about the staff and the morning medications. CM stated that R1's reports different things each time. CM stated that that R1 has gone to the hospital multiple times wherein at one time he/she was not contacted by the facility when he/she went to the facility to visit R1 finding out he/she was not at the facility and this is how she/he found out R1s hospitalization sometime in August but the facility followed up with him/her about R1. CM is stated that R1 was hospitalized about 3 times in the last month but can't remember which one it was specifically but they contacted him/her.

Continuation on LIC 9099-C.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 26-AS-20200804115831
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/27/2023
NARRATIVE
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Page 3 of 3.
Based on R1's medication records review (MARs) for July and August 2020, R1 had 12 medications to be taken in the AM. A review of the facility "Medication Management Log" wherein the staff had to write the date, time, medication/dosage/quantity, reason client did take not take med(s) and staff initials are blank or not filled out. A copy of MARs and Medication Management Log was obtained wherein there missed dates wherein the staff did not provide reasons for why R1 had missed AM medications.

Facility does not contact resident's responsible party when resident is seeking medical services.

On 8/14/2020, ADM stated that R1's daughter/son was not notified when R1 had a fall resulted in hospitalization because he/she was not listed in R1's contact person, nor a consent form to contact R1's daughter/son. ADM stated that R1's case manager was contacted and conservator when R1 was sent to Urgent Care by staff.

Based on R1's General Admission Information form review date updated 6/18/2020, the relative listed was his/her daughter/son. R1 was not conserved, nor he/she had Dual Power Attorney. R1 had a case manager (CM) from Momentum for Mental Health.

Based on interviews and observation/inspection of the facility, the preponderance of evidence standard has been met therefore the above allegations are found to be SUBSTANTIATED.

Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 9099-D.
This report was reviewed with Administrator Maria Canizales and a copy of the report was provided. Appeal Rights was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 26-AS-20200804115831
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/28/2023
Section Cited
CCR
80065(f)(4)
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80065 Personnel Requirements (f)All personnel shall be given on-the-job training or ...related experience...l in the following areas...(4) Assistance with prescribed medications which are self-administered. This requirement is not met as evidenced by:
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Administrator will submit a written plan on understanding regulations and plan of action to ensure staff will assist residents with prescribed medication by POC date.
Administrator verbally understood and agreed.
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Based on record review and interview, R1 was not woken up in the morning to assist R1 with prescribed medications which poses an immediate Health, Safety and Peronal Rights risks to persons in care.
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Type B
08/03/2023
Section Cited
CCR
85075.4(c)
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85075.4 Observation of the Client (c) The licensee shall bring observed changes ... or deterioration of health condition, to the attention of the client's physician and authorized representative, if any.
This requirement is not met as evidenced by:
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Administrator will submit a written plan on understanding regulations and plan of action to ensure authorized representative is notified by licensee about resident observed changes by POC date.
Administrator verbally understood and agreed.
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Based on record review and interview, the facility did not bring observed changed of R1 wherein R1 was sent to the hospital to R1's authorized representative poses a potential Health, Safety, or 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.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4