<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 430700017
Report Date: 10/19/2022
Date Signed: 10/19/2022 01:03:03 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
10/11/2022 and conducted by Evaluator Christine Dolores
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20221011111544
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: 38DATE:
10/19/2022
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Renee SabankayaTIME COMPLETED:
01:20 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not keep the facility free from bed bug infestation
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to open the initial complaint investigation. LPA met with Case Manager (CM), Susana Tobar and Designated Administrator, Renee Sabankaya.

During visit, LPA toured the facility with CM to include 7 resident bedrooms. LPA interviewed 4 staff members and 5 residents. LPA obtained a copy of the resident roster.

Based on interview, 1 out of 5 residents state to have seen and terminated a bed bug at the facility this morning. 5 out of 5 residents state the facility spray and clean their bedrooms every week to treat the bed bugs.

SEE LIC9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022
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-20221011111544
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: 10/19/2022
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
26
27
28
29
30
31
32
4 out of 4 staff members state the facility has ongoing issues with bed bugs. S1 – S2 states this issue is ongoing due to clients bringing items into the facility from the outside. The facility has implemented procedures to treat and eradicate the bed bugs. S1 states this procedure has been implemented since year 2020. S1 states the facility has sought professional treatment and will provide LPA the receipts of the treatment.

LPA observed the facility has multiple containers of bed bug treatment.

Based on interview and observation, the facility is not free of bed bugs.

The Department has conducted an investigation of the above allegation. Based on interviews and observation, the preponderance of evidence standard has been met. Therefore, the Department found the above allegation to be SUBSTANTIATED. A deficiency is being cited per California Code of Regulations, Title 22. See LIC 9099-D.

This report was reviewed with Renee Sabankaya and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 26-AS-20221011111544
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: 10/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/20/2022
Section Cited
CCR
80087(a)(1)
1
2
3
4
5
6
7
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (1) The licensee shall take measures to keep the facility free of flies and other insects.
This requirement was not met as evidenced by:
1
2
3
4
5
6
7
The licensee has corrected the deficiency by implementing procedures to treat and eradicate the bed bugs. The licensee will continue weekly treatment and seek professional treatment if deemed necessary. The licensee will collaborate with Licensing when needed.
8
9
10
11
12
13
14
Based on interview and observation, the facility is not free of bed bugs which poses a potential health, safety, and personal rights risk to persons in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3