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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 04:04:18 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
10/23/2023 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20231023090530

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:
04:15 PM
ALLEGATION(S):
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Staff yelled at resident
Staff did not treat residents with dignity and respect
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 allegations of staff yelled at resident and staff did not treat residents with dignity and respect, RP stated that S4 threatened to have S3 harm me yelling this at me over and over again, yelling that at top of his/her lungs along with I will never sleep at Rivera Villa ever again and live and sleep in jail from now on.

LPA Dolores interviewed R2s case manager (S2), it was stated that R2 is not in the right medication, they do have a right to refuse their medication. When R2 refused his/her injections, R2 has been getting delusion and more thoughts of hurting people. R2 is not like that, he/she is very polite and responsible. Right now, this is not R2. R2 has been refusing his injections for a year. Injections are given by the psychiatrist. R2 has hallucinations and delusions that stays there and then he/she can create a big movie out of it. S2 is not sure if R2 is racist towards S4, but sometimes he/she will say shut up you stupid (slur word). Never witnessed any problem with R2 and other people with S4. Pretty sure R2 has a problem with S3.

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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-20231023090530
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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Additionally, S2 shared that R2 is doing completely opposite things than what is his/her usual behaviors. They’re in contact with doctor and case manager about behaviors. Denied verbal altercations and yelling at them. But states they have to be firm and play along with their delusions and thoughts.

LPA Donato also interviewed the Program Director (PD), it was stated that around this time when the complaint was filed, R2 was not on medication. Crisis team was not responsive, and the behaviors escalated.

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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