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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202511
Report Date: 10/19/2022
Date Signed: 10/19/2022 02:27:58 PM

Document Has Been Signed on 10/19/2022 02:27 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: 38DATE:
10/19/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Renee SabankayaTIME COMPLETED:
01:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management – deficiencies visit. LPA met with Designee Administrator, Renee Sabankaya.

During visit, it was observed the Designee Administrator’s Administrator certificate had expired in 2021. Based on interview, the designee Administrator states a plan to become re-certified.

The listed Administrator and Licensee, Mustafa Sabankaya does currently hold an active Administrator certificate. Based on interview, the listed Administrator does not live in the area and is not on the premises for the number of hours necessary to manage and administer the facility in compliance with applicable law and regulation.

LPA did not observe the Administrator and Designee Administrator on the pending and active administrator certificate list under the CDSS website.

Deficiencies are being cited per California Code of Regulations. Title 22.

A plan of correction was developed during visit. This report was reviewed with Renee Sabankaya and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2022
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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Document Has Been Signed on 10/19/2022 02:27 PM - It Cannot Be Edited


Created By: Christine Dolores On 10/19/2022 at 12:33 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: CLUB RIVIERA
FACILITY NUMBER: 435202511

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/26/2022
Section Cited
CCR
85064(b)

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(b) All adult residential facilities shall have a certified administrator. This requirement was not met as evidenced by:
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Licensee and Designee Administrator will become re-certified and send the proof of certification to LPA via email by POC due date.
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Based on interview, observation, and record review the licensee did not ensure the facility has a certified administrator which poses a potential health, safety, and personal rights risk to persons in care.
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Type B
10/26/2022
Section Cited
CCR85064(e)

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(e) The administrator shall be on the premises the number of hours necessary to manage and administer the facility in compliance with applicable law and regulation. This requirement was not met as evidenced by:
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Licensee will designate a new Administrator at the facility who will meet section 85064. Licensee will send the change of Administrator documents to LPA via email by POC due date.
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Based on interview and observation, the licensee did not ensure the facility’s listed Administrator is on the premises for the number of hours necessary to manage and administer the facility in compliance which poses a potential 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.
SUPERVISOR'S NAME:Sarah Yip
LICENSING EVALUATOR NAME:Christine Dolores
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2022


LIC809 (FAS) - (06/04)
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