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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 04:13:51 PM

Unsubstantiated


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
06/01/2023 and conducted by Evaluator Christine Dolores
COMPLAINT CONTROL NUMBER: 26-AS-20230601104509
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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Staff falsified reports
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 06/01/2023, the Department received the complaint. On 06/08/2023, the initial complaint investigation was conducted. It was alleged facility staff had falsified resident (R1)’s annual report.

The following documents were obtained to include facility’s resident roster, staff schedule, resident (R1)’s physician’s report, appraisal/needs and services plans, admission agreement, identification and emergency information, and email correspondence between R1 and the facility staff. 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: 1 of 2
Control Number 26-AS-20230601104509
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 06/08/2023, 4 staff members were interviewed. Based on interview, R1 was not happy with certain contents of his/her updated appraisal/needs and services plan. R1 became upset with staff and refused to sign the updated appraisal/needs and services plan. Based on interview, the contents of the appraisal/needs and services plan were provided from an evaluation report prior to R1 being admitted to the facility and through observation. 4 out of 4 staff denied falsifying any contents of R1’s appraisal/needs and services plan.

Based on record review, R1’s appraisal/needs and services plan was updated on 04/25/2023. It was noted that R1 did not agree with the contents and provided corrections which have been printed and attached. On 04/25/2023, R1 wrote his/her own appraisal/needs and services plan and provided the copy to the facility. The contents R1 did not agree with were removed in the copy R1 created and provided to the facility.

The Department has investigated the above allegation. Based on interview, record review, and observation, the above allegation is unsubstantiated. An unsubstantiated finding indicates that although the allegation may have happened and/or is valid there is not a preponderance of evidence to prove the alleged violation 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: 2 of 2