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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202511
Report Date: 09/29/2023
Date Signed: 09/29/2023 04:14:56 PM

Document Has Been Signed on 09/29/2023 04:14 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
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 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
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Maria CanizalesTIME COMPLETED:
04:20 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management – other visit. LPA met with Program Director, Maria Canizales.

On 04/26/2023, the Department received a complaint against Ali Baba #1 #430700017 alleging resident (R1)’s physical care was neglected. Upon investigation, it was found R1 was residing at facility (Club Riviera #435202511) during the date of the incident of 03/08/2023.

Throughout the investigation, documents were obtained to include resident roster, staff roster, R1’s emergency contact information, admission agreement, physician’s report, medical records, service plan, R1’s daily logs, and police report.

On 05/03/2023, the initial complaint investigation was conducted. 4 staff members were interviewed. Based on interview, staff members stated R1 is good with personal hygiene. R1 has a lot of anxiety and is transferred to the hospital frequently due to verbalizing health and safety concerns. S3 states they conduct room checks daily and check on R1 daily. 4 out of 4 staff members denied neglecting R1’s physical care. On 05/03/2023, LPA Dolores observed R1 to be well-kept with no observations of dirty skin or clothing, and no foul odor to include the smell of urine or body odor. R1’s room was observed well-kept with clean floors, clean linens, and no foul odor. The review of records show that R1 was transferred to the hospital on 03/08/2023 due to health and safety concerns. R1’s case manager was informed. Based on record review, there was no indication that R1’s physical care was neglected by the facility.

No deficiencies were 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
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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