435202511-5-12-2023-26-AS-KHOS-CSBP5C-20230530110032

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202511
Report Date: 05/12/2023
Date Signed: 05/12/2023 10:18:13 AM

Unsubstantiated

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
05/08/2023 and conducted by Evaluator Christine Dolores

COMPLAINT CONTROL NUMBER: 26-AS-20230508140525

FACILITY NAME:	CLUB RIVIERA		FACILITY NUMBER:	435202511
ADMINISTRATOR:	MUSTAFA SABANKAYA		FACILITY TYPE:	735
ADDRESS:	171 SOUTH 11TH STREET		TELEPHONE:	(408) 289-1644
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95112
CAPACITY:	49	CENSUS: 30	DATE:	05/12/2023
		UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Mustafa Sabankaya		TIME COMPLETED:	10:25 AM

ALLEGATION(S):

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Staff is serving breakfast to residents in an unsanitary manner.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Christine Dolores and Grace Donato arrived unannounced to open the initial complaint investigation. LPAs met with Licensee, Mustafa Sabankaya and Program Director, Maria Canizales.

During visit, LPAs toured the dining room and kitchen area. LPAs observed the dining room was clean and sanitary with wiped down tables and counter tops. The facility's breakfast time started at 8:00am. The facility served cereal, milk, bread, coffee, and peaches. There was a bin filled with used bowls, plates, trays, and utensils with no signs of fecal particles on the dishes. LPAs entered the kitchen area and observed the kitchen was clean and sanitary with wiped down counters and no foul odors.

SEE LIC9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20230508140525

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: CLUB RIVIERA	FACILITY NUMBER: 435202511
	VISIT DATE: 05/12/2023

NARRATIVE

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The refrigerator was maintained at 43 degrees Fahrenheit and contained prepared fruits, milk, bread and other food items. LPAs observed cereals in a clear plastic storage container and was stored in a clean and sanitary manner. There was no observation of any flies, insects, or pests at the facility.

LPAs interviewed 5 residents. Based on interview, the residents state the food being served at the facility is "good". The residents were served different variations of cereal with milk, bread, and coffee this morning. 5 out of 5 residents states the food being served at the facility does not contain unsanitary particles to include feces.

Documents obtained to include resident roster, menu, 2 residents physician's report and appraisal needs and services plan. Resident (R1)'s physician's report and appraisal needs and services plan was requested via email to LPA Dolores before end-of-day.

The Department has investigated the above allegation. Based on interviews conducted records reviewed, and observation the Department has determined that the above allegation is unsubstantiated. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Program Director, Maria Canizales and a copy of the report was provided.

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023

LIC9099 (FAS) - (06/04)

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