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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430701476
Report Date: 05/16/2022
Date Signed: 05/16/2022 05:09:48 PM

Document Has Been Signed on 05/16/2022 05:09 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
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: 10DATE:
05/16/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Renee SabankayaTIME COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Renee Sabankaya.

During visit, LPA Marrufo spoke with Licensee Mustafa Sabankaya over the telephone and explained that the purpose of the visit was to deliver a letter of exclusion for facility staff S1.

Designated Administrator Renee Sabankaya signed the Declaration of Service letters stating that the exclusionary letter for S1 was delivered.

No deficiencies were cited at this time as per California Code of Regulations Title 22.

This report was reviewed with Renee Sabankaya and a copy of the report was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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