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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430701476
Report Date: 06/27/2024
Date Signed: 06/27/2024 05:19:19 PM

Document Has Been Signed on 06/27/2024 05:19 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:ALI BABA # 2FACILITY NUMBER:
430701476
ADMINISTRATOR/
DIRECTOR:		CHERALYNN SABANKAYAFACILITY TYPE:
735
ADDRESS:268 SOUTH 11TH STREETTELEPHONE:
(408) 289-1644
CITY:SAN JOSESTATE: CAZIP CODE:
95112
CAPACITY: 26CENSUS: 9DATE:
06/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:40 AM
MET WITH:Maria CanizalesTIME VISIT/
INSPECTION COMPLETED:
05:25 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual required 1 - year inspection. LPA met with Program Director (PD) Maria Canizales and Financial Auditor (FA) Prunella Cardozo.

During visit, LPA toured the facility with PD and FA to include the resident bedrooms, medication room, kitchen, dining, basement, and exterior. All fire exit routes are free and clear of obstruction. Facility staff present are fingerprint cleared and associated to the facility. Facility temperature maintained at 85 degrees Fahrenheit. Fire extinguishers last serviced on 12/05/2023. Facility has a carbon monoxide detector present in the hallway. Hallways observed with adequate lighting.

With the assistance of PD and FA, LPA entered into resident bedrooms #2, 3, 4, 5, 6, 7, 8, 9. Bedrooms all equipped with bedding, night stand, dresser, and lighting. LPA observed the bedrooms windows of #2 was open and does not contain a window screen.
Bathroom hot water temperature maintained at 116 degrees Fahrenheit.

Facility kitchen observed with at least 2 days worth of perishables and 7 days worth of non-perishable foods. Items in the refrigerator observed covered. Weekly menu and activities posted next to the dining room. Refrigerator temperature maintained at 15 degrees Fahrenheit. The freezer did not contain a thermometer. Items inside the freezer observed cold and frozen. Administrator was advised.

LPA reviewed 3 resident files. Resident files contains a physician's report, TB result, appraisal/needs and services plan, admission agreement, consent forms, identification and emergency contact information, and personal rights. 3 residents centrally stored medications and centrally stored medication records were maintained. SEE LIC809-C.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/27/2024
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 LPA recommended facility to ensure the facility's medication administration records are complete and accurate, to include the correct prescription numbers, start dates, and indicators. Administrator and staff stated understanding. LPA interviewed a resident.

LPA reviewed 3 staff files contained a fingerprint clearance, health screening, TB result, job application, and employee rights. Facility has staff members in the facility who has first aid certification. LPA interviewed staff.

Medication room observed locked and supplied with a first aid kit, PPE supplies, flashlights, batteries, and sharps container.

During visit, LPA obtained the facility's emergency disaster plan and city permit for the outdoor BBQ the Licensee is currently constructing.

The following documents were requested by Monday, 07/01/2024: LIC500, LIC400, Surety Bond, Change of Administrator Documents, and Control of Property.

A deficiency was cited today per California Code of Regulations, Title 22. This report was reviewed with Program Director Maria Canizales and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/27/2024 05:19 PM - It Cannot Be Edited


Created By: Christine Dolores On 06/27/2024 at 04:47 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 06/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(c)
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not ensure bedroom #2's window contained a screen which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/28/2024
Plan of Correction
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Licensee will ensure to install a window screen for bedroom #2. Licensee will submit a picture of the installed window screen to LPA Dolores by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Sarah Yip
LICENSING EVALUATOR NAME:Christine Dolores
LICENSING EVALUATOR SIGNATURE:
DATE: 06/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2024


LIC809 (FAS) - (06/04)
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