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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 04:11:33 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
05/18/2023 and conducted by Evaluator Christine Dolores
COMPLAINT CONTROL NUMBER: 26-AS-20230518100302
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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Activities are not being provided to the residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the finding on the above complaint allegation: LPA met with Program Director, Maria Canizales.

On 05/18/2023, the Department received a complaint regarding the above allegation. On 05/19/2023, the initial complaint investigation was conducted.

From 05/19/2023 – 08/29/2023, documents were obtained to include the facility’s activities calendar.

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-20230518100302
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 05/24/2023, a staff (S1) was interviewed. It was stated that the facility does not currently provide activities for the residents due the COVID-19 restrictions. Based on record review and observation, the facility also does not have an activities calendar.

Based on interview and record review, the facility began implementing activities on 06/06/2023.

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

A deficiency is 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 along with the appeal rights.
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
05/18/2023 and conducted by Evaluator Christine Dolores
COMPLAINT CONTROL NUMBER: 26-AS-20230518100302

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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Administration are not answering resident’s family members in a timely manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the finding on the above complaint allegation: LPA met with Program Director, Maria Canizales.

On 05/18/2023, the Department received a complaint regarding the above allegation. It was alleged that the facility staff are not answering resident (R1’s) family member in a timely manner. On 05/19/2023, the initial complaint investigation was conducted.

From 05/19/2023 – 08/29/2023, documents were obtained to include email correspondences and letters between the facility and R1's family member.

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-20230518100302
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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Based on interview, the facility does try to communicate with family members in a timely manner either via telephone call or emails. S1 states the facility was having technical difficulties with their telephone in which they were receiving telephone calls but no voicemails.

Based on record review, there was not enough evidence to prove R1’s family member was not being answered by the facility's administration in a timely manner either via telephone call or via email.

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

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
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 26-AS-20230518100302
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 B
09/29/2023
Section Cited
CCR
85079(d)
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(d) In facilities with a licensed capacity of seven or more clients, notices of planned activities shall be posted in a central facility location readily accessible to clients, relatives, and representatives of placement and referral agencies. This requirement is not met as evidenced by:
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Licensee has corrected deficiency prior to visit by providing the activities calendar. Licensee will ensure the activities calendars are posted in an accessible area for review. POC CLEARED.
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Based on record review, interview, and observation the licensee did not ensure residents are provided planned activities which poses/posed 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.
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