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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202511
Report Date: 04/18/2024
Date Signed: 04/18/2024 04:20:51 PM

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
04/03/2024 and conducted by Evaluator David Marrufo
COMPLAINT CONTROL NUMBER: 26-AS-20240403110356
FACILITY NAME:CLUB RIVIERAFACILITY NUMBER:
435202511
ADMINISTRATOR:MUSTAFA SABANKAYAFACILITY TYPE:
735
ADDRESS:171 SOUTH 11TH STREETTELEPHONE:
(408) 289-1644
CITY:SAN JOSESTATE: CAZIP CODE:
95112
CAPACITY:49CENSUS: 31DATE:
04/18/2024
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Prunella CardozoTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Staff does not treat resident with respect.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Prunella Cardozo. The Department received a complaint with the above allegation on 04/03/2024. An initial complaint investigation visit was conducted on 04/10/2024.

During interview, resident R1 stated that the facility Licensee came to R1’s bedroom and tried to take R1’s curling iron and accused R1 of smoking in R1’s bedroom.

During interview, Licensee stated to have not come into R1’s bedroom and to have never seen R1.

R1 stated that staff S1 “snapped” at R1 several times.

See LIC9099-C for more information. Page 1 of 2.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024
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 2
Control Number 26-AS-20240403110356
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: 04/18/2024
NARRATIVE
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During interview, S1 stated to have never been disrespectful to R1. S1 stated to have never snapped at R1 and to have not observed any other staff snapping or responding angrily at R1.

LPA Marrufo interviewed staff S2, who works in the facility kitchen. S2 stated during interview that PD told S2 to store R1’s food in the facility kitchen refrigerator.

LPA Marrufo observed a plate of food in the kitchen wrapped in saran wrap. The saran wrap had a sticker with R1’s name on it. LPA observed a plate covered in tin foil in the refrigerator and the tin foil had R1’s name on it. LPA observed a bag in the refrigerator wit R1’s name on it. LPA also observed plastic bins with snacks inside and labels with other residents’ names on them on a shelf next to the refrigerator.

Based on information from interviews conducted with staff, and observations made, although the allegation listed above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is unsubstantiated.

No Deficiencies were cited under California Code of Regulations Title 22

This report was reviewed with Prunella Cardozo and a copy of this report was provided.



Page 2 of 2.

END REPORT
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2