430700017-8-15-2023-26-AS-KHOS-CV5JG7-20230828070152

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 430700017
Report Date: 08/15/2023
Date Signed: 08/15/2023 05:46:09 PM

Unsubstantiated

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
09/15/2020 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20200915084419

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: 41	DATE:	08/15/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Brian Castenada		TIME COMPLETED:	06:00 PM

ALLEGATION(S):

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Staff failed to protect resident from being harmed by another resident.
Facility failed to protect resident's personal right of safe accommodation
Facility failed to report missing resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation and met with Brian Castenada.

On 09/15/2020, the Department received a complaint with the above allegations. The Department conducted complaint investigation visits on 09/24/2020 and 07/27/2023.

R1 did not have an Appraisal/Needs and Services Plan in R1’s resident records. R1 had a Service Application/Authorization Form which stated that R1 had a history of violent behavior revolving around R1’s delusions but had not had an incident of violent behavior since R1’s admission date.
R2’s Appraisal/Needs And Services Plan dated 01/01/2018 states that R2 is very kind and sociable and gets along with staff and residents.

See LIC9099-C for more information. Page 1 of 2.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023

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 3

Control Number 26-AS-20200915084419

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: 08/15/2023

NARRATIVE

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The LIC624 Unusual Incident Report (IR) submitted to the Department on 09/13/2020 states that on 09/13/2020, staff S1 observed resident R1 on the ground on top of R2 and pinning R2 to the ground.

The IR states that the immediate action S1 took was to call 911.

The IR does not state what the facility action plan was to ensure that R1 and R2 did not cause any harm to one another after each of them returned to the facility.

R1’s Medication Log states R1 was living in the Palms House R2’s Medication Log states that R2 was living in the Main House during the time of the incident reporting in the IR.

S2 stated to not be able to find any action plan about how staff would ensure that R1 and R2 were not involved in another altercation with each other.

R4’s Physician’s Report states R4 is able to leave the facility unassisted.

A Police Report dated 09/06/2020 states that S1 reported to police on 09/05/2020 that R4 had left the facility without permission and had not returned by 11PM curfew. The Police Report states that Emergency Psychiatric Services (EPS) had found R4 on 09/14/2020 at 9:50 PM.

R4’s Medication Administration Record (MAR) states that on 09/05/2020 R4 took morning medications and was absent for the evening medications.

On 08/15/2023, LPA Marrufo interviewed staff S2, who stated to not be able to find any earlier Daily Logs on R4’s absence from the facility or any LIC624 Unusual Incident Report.

Based on information from interviews conducted with staff and residents, and records reviewed, although the allegations listed above may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are unsubstantiated.

No Deficiencies cited under California Code of Regulations Title 22. This report was reviewed with Brian Castenada and a copy of this report was provided. Page 2 of 2. END REPORT.

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3