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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202511
Report Date: 09/29/2023
Date Signed: 09/29/2023 04:06:24 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
09/28/2022 and conducted by Evaluator Christine Dolores
COMPLAINT CONTROL NUMBER: 26-AS-20220928082335
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: 26DATE:
09/29/2023
UNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Maria CanizalesTIME COMPLETED:
04:20 PM
ALLEGATION(S):
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Staff did not prevent resident from becoming infested with bed bugs while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the findings on the above complaint allegations. LPA met with Program Director, Maria Canizales.

On 09/28/2022, the Department received the complaint. On 09/29/2022, the initial complaint investigation was conducted.

The following documents were obtained to include resident roster, resident (R1)’s medical records, identification and emergency contact information, shower tracker, laundry log, daily logs, admission agreement, incident reports, and resident (R1) – (R3)’s physicians report and needs and services plan. SEE LIC9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023
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 5
Control Number 26-AS-20220928082335
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: 09/29/2023
NARRATIVE
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On 09/21/2022, R1 was admitted at the hospital where it was determined R1 had bed bugs on him/her. Based on interview with staff (S1), it was stated that this was the second time this issue with bed bugs has happened with R1 as R1 refuses to remove his/her items and have them cleaned. S1 stated that the facility will clean R1’s items and provide R1 with a new room upon return.

The Department has investigated the above allegations. Based on interview, record review and observation the preponderance of evidence has been met, therefore, the allegation is substantiated.

A deficiency is being cited per Calfiornia Code of Regulations, Title 22. See LIC9099-D.

This report was reviewed with Program Director, Maria Canizales and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
09/28/2022 and conducted by Evaluator Christine Dolores
COMPLAINT CONTROL NUMBER: 26-AS-20220928082335

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: 26DATE:
09/29/2023
UNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Maria CanizalesTIME COMPLETED:
04:20 PM
ALLEGATION(S):
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Resident is being harassed while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the findings on the above complaint allegations. LPA met with Program Director, Maria Canizales.

On 09/28/2022, the Department received the complaint. On 09/29/2022, the initial complaint investigation was conducted.

The following documents were obtained to include resident roster, resident (R1)’s medical records, identification and emergency contact information, shower tracker, laundry log, daily logs, admission agreement, incident reports, and resident (R1) – (R3)’s physicians report and needs and services plan. SEE LIC9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 26-AS-20220928082335
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: 09/29/2023
NARRATIVE
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It was alleged resident (R1) was being harassed in the facility, however, it was not clear how R1 was being harassed.

On 09/29/2023, 1 staff (S1) member was interviewed. Based on interview, the facility observed R1’s health start to decline wherein R1 was refusing showers and housekeeping. R1 was observed to use the bathroom sink to wash clothing where staff had to talk to the resident. S1 state R1 took the feedback positively. S1 denied ever harassing the resident.

On 09/29/2023, 1 witness (W1) was interviewed. Based on interview, W1 was not aware of any incidents of R1 being harassed in the facility. W1 states when R1 is declining his/her perceptions, ideas, and encounters may change.

Based on record review, R1 was admitted to the hospital on 09/21/2022. R1 was discharged from the facility due to the need of higher level of care.

The Department has investigated the above allegation. Based on interview, record review, and observation the above allegation is unsubstantiated. An unsubstantiated finding indicates that although the allegations may have happened and/or is valid there is not a preponderance of evidence to prove the alleged violation did or did not occur.

No deficiencies are being cited per California Code of Regulations, Title 22.

This report was reviewed with Program Director, Maria Canizales and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 26-AS-20220928082335
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: 09/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/30/2023
Section Cited
CCR
80072(a)(2)
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(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirement is not met as evidenced by:
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Licensee will submit the facility's policy and procedures regarding bugs in resident's rooms and facility's pest control schedule and receipts to LPA Dolores by POC due date.
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Based on interview, record review and observation the licensee did not ensure resident (R1) was accorded a safe, healthful, and comfortable accommodation due to bed bugs in R1's room which poses an immediate health, safety, and personal rights risk to persons 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: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5