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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202511
Report Date: 02/20/2025
Date Signed: 02/20/2025 01:42:02 PM

Document Has Been Signed on 02/20/2025 01:42 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/
DIRECTOR:		MUSTAFA SABANKAYAFACILITY TYPE:
735
ADDRESS:171 SOUTH 11TH STREETTELEPHONE:
(408) 289-1644
CITY:SAN JOSESTATE: CAZIP CODE:
95112
CAPACITY: 49CENSUS: 28DATE:
02/20/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:20 PM
MET WITH:Prunella CardozoTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Christine (Dolores) Kabariti arrived at the facility unannounced to conduct a case management – other visit. LPA met with Designated Administrator Prunella Cardozo.

The purpose of the visit is to hand deliver an immediate exclusion letter for an individual (S1) who the Department determined engaged in conduct inimical.

Designated Administrator confirmed S1 was not currently working in the facility. Based on review of the facility's staffing schedule, S1 was not listed in the schedule.

The immediate exclusion letter was handed to the designated administrator.

The designated administrator was informed to remove S1 from any contact with clients and not allow S1 to be physically present in the facility.

The designated administrator was advised to separate S1 from the facility roster.

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

This report was reviewed with Prunella Cardozo and a copy of the report was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Kabariti
LICENSING EVALUATOR SIGNATURE: DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/20/2025
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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