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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202511
Report Date: 05/03/2023
Date Signed: 05/03/2023 12:26:11 PM

Document Has Been Signed on 05/03/2023 12:26 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: DATE:
05/03/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Renee SabankayaTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Dolores arrived to the facility unannounced to open a complaint investigation. During visit, a case management - deficiencies visit was conducted due to violations observed. LPA met with Designated Administrator, Renee Sabankaya.

On two occasions, a resident (R1) was sent for medical treatment to Emergency Psychiatric Services (EPS). Based on review of the facility's incident reports, the facility did not submit an incident report to the Department for both occasions.

During visit, staff provided the incident reports to designated Administrator and LPA. Based on interview, the incident reports were not seen by the designated Administrator therefore could not confirm if the incident reports were sent to the Department.

LPA printed out the Title 22 regulation on reporting requirements and provided the section to the designated Administrator. LPA advised the designated Administrator to ensure staff are filling out each section on the incident report to include the second page. Designated Administrator stated understanding.

In the dining room, LPA observed a cracked mirror panel with cracked shards on the wall that is not observed covered. Based on interview it was stated R1 had broken the mirror with an object more than three months ago. LPA advised facility to ensure the cracked mirror is covered to ensure resident's safety while they wait for repair. Designated Administrator stated understanding.

Deficiencies were cited per California Code of Regulations, Title 22. See LIC809-D. 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: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2023
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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Document Has Been Signed on 05/03/2023 12:26 PM - It Cannot Be Edited


Created By: Christine Dolores On 05/03/2023 at 12:08 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: 05/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/04/2023
Section Cited
CCR
80061(b)(1)(D)

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(b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event. (1) Events reported shall include the following: (D) Any injury to any client which requires medical treatment. This requirement is not met as evidenced by:
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Licensee will ensure to review section 80061. Licensee will re-train staff on reporting requirements and the proper way to write an incident report. Licensee will submit a statement of understanding of section 80061 and the training documentation to LPA via email by POC due date.
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Based on observation, record review, and interview the facility did not submit an incident report for R1 on two occasions of required medical treatment which poses an immediate health, safety, and personal rights risk to persons in care.
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Type A
05/04/2023
Section Cited
CCR80087(a)

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(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
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Licensee covered the cracked mirror panel during visit. Licensee will submit a written plan to repair the mirror in the dining room to LPA by POC due date.
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Based on observation and interview, the facility's dining room has an exposed cracked mirror panel for more than three months 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.
SUPERVISOR'S NAME:Sarah Yip
LICENSING EVALUATOR NAME:Christine Dolores
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2023


LIC809 (FAS) - (06/04)
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