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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202511
Report Date: 11/19/2024
Date Signed: 11/19/2024 03:42:24 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
11/15/2021 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20211115164116
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: 34DATE:
11/19/2024
UNANNOUNCEDTIME BEGAN:
09:47 AM
MET WITH:Maria CanizalesTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Unqualified personnel are assisting residents with medications
Facility staff do not supervise volunteers
INVESTIGATION FINDINGS:
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On 11/19/2024, LPA Grace Donato conducted an unannounced complaint investigation visit. LPA met with Program Director, Maria Canizales and LPA explained the purpose of the visit.

Regarding the allegation of unqualified personnel are assisting residents with medications, reporting party (RP) stated that a staff member S1, has been working in the medication room assisting residents with medications during the evening shifts.

LPA Marrufo interviewed seven residents. Five of the residents mentioned that they haven’t seen S1 in the med room. However, two other residents (R2 & R5) had a different observation. R2 mentioned that S1 works in the med room maybe once or twice a year, last time seen was over a month ago to cover a staff that was on vacation. R5 has mentioned another staff, S2, did a good job passing out medications.

page 1 of 2
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024
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 4
Control Number 26-AS-20211115164116
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: 11/19/2024
NARRATIVE
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S1 and S2 were also interviewed and S1 stated that there was a shift that was covered a couple of times because a staff went on vacation. S1 has never passed out medications. The evening medications are passed out at 7pm. S2 admitted to passing medications. In S2s statement, it was stated that he/she passes out pills, answer phone calls, make sure there is peace and quiet. S2 doesn’t do any paperwork like logging of medications. S2 also shared that he/she does know how to pass out meds and have clients sign and initial.

For the allegation of facility staff do not supervise volunteers, RP stated that the management schedules unqualified personnel to be inside the medication rooms and distribute and assist residents with medications during the evening work shifts.

On 05/06/2022, LPA Marrufo interviewed former Administrator (ADM), who confirmed S2 was indeed a volunteer and not a paid staff at the facility.

During the interview of S2, it was also mentioned that S2 have worked in the facility medication room on an emergency basis when a staff was not available to work in the medication room. S2 stated that no one else is in the med room with S2 when S2 is covering for emergencies.

Based on interviews and records review and information collected, the above allegations are determined to be SUBSTANTIATED. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties.

Report is reviewed and a copy of this report and appeal rights are provided.

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SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 26-AS-20211115164116
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/20/2024
Section Cited
CCR
80065(f)(4)
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80065 Personnel Requirements (f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas... (4)Assistance with prescribed medications which are self-administered.
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Licensee agrees to submit a plan by POC date to ensure that only qualified staff, and not volunteers, are tasked with providing assistance to residents with administration of medications.
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This was not met as evidenced by: Licensee did not ensure that only qualified staff were assisting residents with administration of medications, which poses an immediate safety risk to residents in care.
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Type A
11/20/2024
Section Cited
CCR
80065(c)
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80065(c) Personnel Requirements: The licensee shall be permitted to utilize volunteers provided that such volunteers are supervised, and are not included in the facility staff plan.
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Licensee agrees to develop a plan to ensure that volunteers are always supervised at the facility and not included in the facility staff plan. Licensee agrees to submit the plan to CCL by POC date.
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This was not met as evidenced by: The licensee did not ensure that S2 was supervised and not included in the facility staff plan, which poses an immediate safety risk to residents 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: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
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
11/15/2021 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20211115164116

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: 34DATE:
11/19/2024
UNANNOUNCEDTIME BEGAN:
09:47 AM
MET WITH:Maria CanizalesTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility does not employ adequate staff as necessary to meet residents' needs
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
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9
10
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12
13
On 11/19/2024, LPA Grace Donato conducted an unannounced complaint investigation visit. LPA met with Program Director, Maria Canizales and LPA explained the purpose of the visit.

Regarding the allegation of facility does not employ adequate staff as necessary to meet residents' needs, RP states that the reason S1 and S2 have started working the evening shifts in the medication rooms is because the facility does not employ enough staff.

According to the seven residents interviews, all stated that there are enough staff in the facility to meet their needs. With regards to the three staff interviews, all mentioned too that there is enough staff.

Based on interviews, the department has determined that although the allegations 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.

Report is reviewed and copy is provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4