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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 430700017
Report Date: 08/15/2023
Date Signed: 08/15/2023 05:50:55 PM

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
10/21/2021 and conducted by Evaluator David Marrufo
COMPLAINT CONTROL NUMBER: 26-AS-20211021104020
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: 41DATE:
08/15/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Brian CastenadaTIME COMPLETED:
06:15 PM
ALLEGATION(S):
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Staff are not administering medications as ordered by physician.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Brian Castenada.

The Department received a complaint with the above allegations on 10/21/2021. On 10/27/2021, 11/05/2021, and 07/27/2023, the Department conducted complaint investigation visits.

On 11/05/2021, LPA Marrufo conducted a medication review of resident R1’s medications. LPA Marrufo reviewed R1’s Medication Administration Record (MAR) and Centrally Stored Medication Log and had staff count R1’s remaining medication pills from the medication containers. During medication review, LPA Marrufo observed that R1 was missing 5 amlodipine pills. R1’s MAR and Centrally Stored Medication Log listed amlodipine as one of R1’s prescribed medications.
See LIC9099-C for more information. Page 1 of 2.
Substantiated
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 5
Control Number 26-AS-20211021104020
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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Based on records review, interviews with staff and residents, and observations there is preponderance of evidence to prove the alleged violation did occur; therefore, the allegation is substantiated.

See 9099-D for deficiencies cited per the California Code of Regulations, Title 22.

This report was reviewed with Brian Castenada and a copy of this report and appeal rights were 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 5
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
10/21/2021 and conducted by Evaluator David Marrufo
COMPLAINT CONTROL NUMBER: 26-AS-20211021104020

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:
08/15/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Maria CanizalesTIME COMPLETED:
06:15 PM
ALLEGATION(S):
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Facility does not provide adequate food service.
Client's property was stolen.
INVESTIGATION FINDINGS:
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**Report Amended on 02-02-2024 to reopen the complaint investigation and conduct further interviews**R1’s Physician’s Report states R1 does not have a special diet. R1’s Physician’s Report states R1 has bowel impairment with a comment of “frequent vomit and diarrhea.”

On 10/27/2021, LPA Marrufo observed lunch meal service and interviewed 2 staff and 4 residents during their meal. LPA Marrufo observed residents being served hamburgers, soup, and mashed potatoes. 3 out of 4 interviewed residents stated that they liked the food at the facility and the food was not too spicy. 1 out of 4 residents stated the food was too spicy and greasy. 2 out of 2 staff stated the food is not too spicy and that alternate meals such as peanut butter and jelly sandwiches are available upon request from residents.

On 10/27/2021, LPA Marrufo interviewed 6 additional residents. 6 out of 6 interviewed residents stated the food served at the facility is adequate. 2 out of 6 interviewed residents stated the food served is too spicy. 4 out of 6 stated the food served is not too spicy. 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: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 26-AS-20211021104020
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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**This report was amended on 02-02-2024 to reopen the complaint investigation and conduct further interviews**R1’s Safeguard of Property and Valuables form lists R1’s iPhone, Android, and Laptop as safeguarded valuables. During interview on 10/27/2021, R1 stated to have experienced clothing, $40, and other belongings go missing. R1 stated that the facility staff provided R1 with 3 safes, but then staff only allowed R1 to have 1 safe. R1 stated that R1's scooter and charging cable for the scooter went missing but were later found near another resident’s room. LPA Marrufo interviewed residents R2-R6 on 10/27/2021. R2 stated to have had R2's shoes ripped apart and stated that that there are many thefts in the facility. R2 stated that residents steal cigarettes from each other. R4 stated that someone was arrested for stealing, but did not specify who it was or what items were stolen. R6 stated that other residents have stolen belongings from other residents, but did not say if R6's belongings have been stolen or provide any further details. R3 and R5 stated that residents at the facility do not steal the property of others. On 02/02/2024, LPA Marrufo interviewed staff S1-S5. Staff S1 stated to not know if any of R1's clothing were thrown out and was not sure if R1's scooter charging cable was lost. S2 stated that R1's clothes were never thrown out and could not recall if R1's charging cable was lost. S3 stated to not know if R1's clothes were thrown out or if R1's scooter charging cable was lost. S4 and S5 stated to not recall if R1's clothes were ever thrown out, but that S4 and S5 always contact resident's case managers and family members before throwing out any clothes. S4 and S5 stated that R1 arrived at the facility with many clothing items that were not fitting in R1's private bedroom. S4 and S5 stated that R1 initially had three safes, but R1 would store food items in the safe that went against R1's dietary plan. S4 and S5 stated that R1 was allowed to charge R1's scooter by using a power outlet on the outside of the facility medication room and was allowed to store R1's charging cable underneath the stairway on the side of the medication room. S4 and S5 stated to not recall if R1's scooter charging cable was lost. S1-S5 stated that the facility prevents theft of resident belongings by preventing residents from going into each other's bedrooms and providing each resident with a safe in their bedrooms. S3 stated that staff will keep lost items until a resident reports that they are missing and will provide residents with money to buy more cigarettes if the resident reports that cigarettes were stolen from them. Based on information from interviews conducted with staff, 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 Maria Canizales, Program Director, 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: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 26-AS-20211021104020
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: 08/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/16/2023
Section Cited
CCR
80075(b)
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80075(b) Health Related Services (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.
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Licensee agrees to submit a plan by POC date to audit resident medications and train staff on proper assistance with and documentation of medication administration.
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This requirement was not met as evidenced by: Upon medications review, R1’s medications were found to have 5 missing pills of amlodipine prescription medication, which poses an immediate health and safety risk to residents in care.
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Once training and audits are completing, licensee shall submit audit and training records to CCL with names of staff trained, training dates, and training topic(s) to CCL.
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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: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5