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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 03:51:15 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
01/13/2022 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20220113151611
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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Staff do not give medication according to physician orders
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 staff do not give medication according to physician orders, reporting party (RP) stated that resident (R1) was sent home to a family member (F1), with over a dose of 800ml of medication (M1). RP states that this dosage is way too much medication and that this is not the dosage that is prescribed by the resident's physician. RP states that on 1/11/2022, R1 was sent home to family again with the wrong dosage of M1. This time the R1 was provided 200ml over the prescribed dosage for the medication.

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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 3
Control Number 26-AS-20220113151611
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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During the interview of a staff member (S1), it was mentioned that on 01/07/2022, about 2:30, S1 got here to the facility to check on the morning staff since they are fairly new. S1 saw that R1s F1 was upset and demanding a recount of the meds. S1 found that it was two days more of the bedtimes. S1 thought that was 2-3 extra pills over the medications. The rest of the meds were okay and correlated with the MAR. S1 apologized for the meds and said it was the NOC shift that packed the meds. When F1 left, they took the right medication home.

According to the daily logs provided by the facility, an entry on 1/07/2022 at 3:55pm, noted that staff got a call from Momentum that F1 went to talk to them about R1s medication. Staff spoke with Nurse from doctor’s office to confirm if the prescription order of M1 sent from Momentum was in steps 1-3 because staff followed the instruction from the paperwork and also informed the nurse that Momentum did not update pharmacy regarding the prescription order sent to facility as pharmacy still follow R1s old med list. Nurse apologized and said they will send the prescription order to pharmacy after he/she drop the call with staff and also will tell F1 to give R1 100mg on date 7th and 200mg starting date 8th and bring the rest back to facility.

Based on the Medication Administration Records (MAR) obtained, on the dates of 1/6-7/2022, there were no logs of medication being given to resident.

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 3
Control Number 26-AS-20220113151611
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
80075(b)
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80075 Health Related Services (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.
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Licensee agrees to develop a plan to ensure that an accurate documentation of medications given to residents are accurate and to ensure that residents are given the correct dosages of medication. Licensee agrees to submit the plan to CCL by POC date.
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This was not met as evidenced by: Based on interviews and records review, facility made an error with the medication for S1, according to MAR there was no log of medication given to S1, 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)
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