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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 05:59:20 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
11/15/2021 and conducted by Evaluator David Marrufo
COMPLAINT CONTROL NUMBER: 26-AS-20211115155533
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:
06:30 PM
ALLEGATION(S):
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Unqualified personnel are assisting residents with medications
Facility staff do not supervise volunteers
Facility does not employ staff as necessary to meet residents' needs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Brian Castenada.

On 11/15/2021, the Department received a complaint with the above allegations. On 11/19/2021, LPA Marrufo conducted an unannounced complaint investigation visit.

On 05/06/2022, LPA Marrufo interviewed former Administrator (ADM), who confirmed volunteer V1 was indeed a volunteer and not a paid staff at the facility.

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 4
Control Number 26-AS-20211115155533
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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On 11/19/2021, LPA Marrufo interviewed V1. During interview, V1 stated have worked in the facility medication room on an emergency basis when a staff was not available to work in the medication room. V1 stated to have passed medications to residents while unsupervised by a facility staff in the medication room.

On 11/19/2021, LPA Marrufo obtained a copy of May Medication Work Schedule for May 10-20, 2021 The staff schedule had a handwritten note stating that V1 must approve of any changes and a telephone number written below the note. The work schedule states V1 was assigned to work on May 7th and May 8th from 7:00 AM – 3:30 PM.

On 11/19/2021, LPA Marrufo interviewed 6 residents. 3 out of 6 residents stated to have observed V1 working alone in the medication room, and 2 of those 3 residents specified to have observed V1 passing out medications.

Based on records review and interviews with staff and residents, there is preponderance of evidence to prove the alleged violations 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.
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 4
Control Number 26-AS-20211115155533
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
80065(f)(4)
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80065(f)(4) Personnel Requirements: All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance.
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Licensee agrees to submit a plan by POC date to ensure that only qualified staff, and not volunteers, are tasked with providing assistance to residents with administration of medications.
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 Assistance with prescribed medications which are self-administered. This requirement was not met as evidenced by: Licensee did not ensure that only qualified staff were assisting residents with administration of medications, which poses an immediate safety risk to residents in care.
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Type A
08/16/2023
Section Cited
CCR
80065(c)
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80065(c) Personnel Requirements: The licensee shall be permitted to utilize volunteers provided that such volunteers are supervised, and are not included in the facility staff plan.
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Licensee agrees to develop a plan to ensure that volunteers are always supervised at the facility and not included in the facility staff plan. Licensee agrees to submit the plan to CCL by POC date.
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This requirement was not met as evidenced by: The licensee did not ensure that volunteer V1 was supervised and not included in the facility staff plan, which poses a an immediate safety risk to residents 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: 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: 3 of 4
Control Number 26-AS-20211115155533
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
80065(a)
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80065(a) Personnel Requirements: (a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.
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Licensee agrees to submit a plan to CCL by POC date to ensure that facility personnel are employed in numbers necessary to meet resident needs.
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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: 4 of 4