435202511-5-7-2025-26-AS-KHOS-DGLMHY-20250512093820

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202511
Report Date: 05/07/2025
Date Signed: 05/07/2025 02:05:26 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
11/13/2024 and conducted by Evaluator Jaime Vado

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20241113120859

FACILITY NAME:	CLUB RIVIERA		FACILITY NUMBER:	435202511
ADMINISTRATOR:	MUSTAFA SABANKAYA		FACILITY TYPE:	735
ADDRESS:	171 SOUTH 11TH STREET		TELEPHONE:	(408) 289-1644
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95112
CAPACITY:	49	CENSUS: 34	DATE:	05/07/2025
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Administrator - Prunella Cardozo		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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- Staff did not provide resident medication as prescribed
- Staff did not inform resident's responsible party about resident's change of condition

INVESTIGATION FINDINGS:

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On 05/07/2025, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit in order to deliver findings regarding the allegations received. LPA met with Administrator - Prunella Cardozo and explained the purpose of today's visit.

During the investigation, LPAs conducted interviews, collected and reviewed pertinent documents, and made observations. During the investigation, LPAs conducted interviews, collected and reviewed pertinent documents, and made observations. As a result of the investigation, LPAs could not prove or disporve these allegations took place. Documentation, observations, and interviews are contrary to what the allegations state. It was noted that the resident would stay out past curfew hours and would miss medications and during the day would not go to the medication room to receive them. Also noted is that the responsible party at the time was Telecare, not the complainant. These allegations are unsubstantiated.

During the investigation, LPAs conducted interviews, collected and reviewed pertinent documents, and made observations. As a result of the investigation, LPAs could not prove or disporve these allegations took place. Documentation, observations, and interviews are contrary to what the allegations state. These allegations are unsubstantiated. Report is reviewed with Administrator Prunella Cardozo and a copy is provided.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2025

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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