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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 430701476
Report Date: 05/16/2024
Date Signed: 05/16/2024 04:58:09 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
05/16/2024 and conducted by Evaluator Christine Dolores
COMPLAINT CONTROL NUMBER: 26-AS-20240516154300
FACILITY NAME:ALI BABA # 2FACILITY NUMBER:
430701476
ADMINISTRATOR:CHERALYNN SABANKAYAFACILITY TYPE:
735
ADDRESS:268 SOUTH 11TH STREETTELEPHONE:
(408) 289-1644
CITY:SAN JOSESTATE: CAZIP CODE:
95112
CAPACITY:26CENSUS: 9DATE:
05/16/2024
UNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Maria CanizalesTIME COMPLETED:
05:05 PM
ALLEGATION(S):
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Staff did not ensure admission agreement was provided to client
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to open the initial complaint investigation. LPA met with Program Director (PD) Maria Canizales.

On 05/13/2024, the Department received a complaint regarding the above allegations. On 05/16/2024, the initial complaint investigation was conducted.

The following documents were obtained to include the resident roster, staff schedule from April - May 2024 and resident (R1)'s admission agreement.

On 05/10/2024, R1 was transferred from Club Riviera #435202511 to Ali Baba #2. Based on record review, R1 did not sign an updated admission agreement when he/she was transferred to Ali Baba #2. PAGE 1 OF 2.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024
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-20240516154300
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 # 2
FACILITY NUMBER: 430701476
VISIT DATE: 05/16/2024
NARRATIVE
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R1's current admission agreement on file is for facility Club Riviera #435202511. The facility provided LPA Dolores a copy of R1's admission agreement addendum to include R1's current site location, Ali Baba #2.

The admission agreement addendum has not yet been reviewed, signed and dated by R1.

The Department has investigated the above allegation. Based on interview, record review and observation the preponderance of evidence standard has been met, therefore, the above allegation is substantiated. A deficiency was cited per California Code of Regulations, Title 22. LIC9099-D. This report was reviewed with Program Director, Maria Canizales and a copy of the report and appeal rights was provided.

PAGE 2 OF 2.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 26-AS-20240516154300
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 # 2
FACILITY NUMBER: 430701476
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/23/2024
Section Cited
CCR
80086(a)
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(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any. This requirement is not met as evidenced by:
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Licensee will have R1 sign the admission agreement addendum by 05/17/2024. Licensee will submit to a written plan to ensure compliance with the section cited by POC due date.
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Based on interview, record review, and observation the licensee did not ensure resident (R1) signed a new admission agreement when R1 was transferred to Ali Baba #2 on 05/10/24 which poses a potential health, safety, and 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: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5