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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202511
Report Date: 01/28/2025
Date Signed: 01/28/2025 01:19:24 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
05/09/2024 and conducted by Evaluator Jaime Vado
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20240509105521
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: 28DATE:
01/28/2025
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Case Manager - Susana TovarTIME COMPLETED:
01:00 PM
ALLEGATION(S):
1
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5
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7
8
9
- Staff did not provide resident medication as prescribed
- Staff are not providing adequate food service
INVESTIGATION FINDINGS:
1
2
3
4
5
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7
8
9
10
11
12
13
On 01/28/2025, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit in order to deliver findings regarding the allegation received. LPA met with case manager Susana Tovar and explained the purpose of today's visit.

During the investigation interviews were conducted, files were reveiwed, and observations were made. Per interviews conducted, interviews, and records reviewed the facility did prescribe the medications as needed based on medication administration records reveiwed and interviews. The resident would also refuse medications at times and would self admit to emergency to obtain medications. In regards to food service, food supplies were observed, and interviews showed that the residents are allowed to store food but are still offered food. Based on information received, these allegations are unsubstatiated.

Based on these observations, the above allegations are UNSUBSTANTIATED.
Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated at this time. Report is reviewed with assistant administrator Prunella Cardozo.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025
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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