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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 04:09:06 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
11/02/2023 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20231102111319
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:
04:25 PM
ALLEGATION(S):
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Facility staff engaged in an altercation with resident.
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 that facility staff engaged in an altercation with resident, reporting party (RP) stated that on 8/5/2023 facility staff engaged in an altercation with resident (R1).

Based on records review, an incident report was already submitted to Licensing regarding this issue. The incident is about R1 going into other residents room and through their drawers. Staff (S1) warned R1 to stop then R1 became aggressive. R1 hit S1 and destroyed a vase.

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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)
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Control Number 26-AS-20231102111319
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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On the police report obtained, it was reported that the officer (P1) made contact with S1. S1 stated that he/she did not want to press charges for R1 attacking him. P1 also made contact with R1. R1 told P1 that
he/she was hearing voices telling him/her to kill himself/herself. R1 also stated that he/she heard the voices telling him to attack other people. Based on the statement's of R1, P1 believed he/she was a danger to himself/herself and a danger to others due to a mental disorder and placed R1 on a 5150 hold. P1 transported R1 to EPS for a psychiatric evaluation.

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.

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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)
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