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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202511
Report Date: 01/03/2024
Date Signed: 01/04/2024 08:16:30 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/26/2020 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20200626145201
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: 24DATE:
01/03/2024
UNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Maria CanizalesTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility mismanages residents' medications
Facility does not have sufficient food supply for emergencies
Administrator is not present at the facility enough to manage and administer the facility
INVESTIGATION FINDINGS:
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On 1/03/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced visit to deliver findings for the above allegations. LPA met with Program Director (PD) Maria Canizales and explained the purpose of today's visit.

Regarding the allegation of facility mismanages residents' medications, reporting party (RP) mentioned that there are two residents, who were given wrong medication.

Based on interviews by LPA Marrufo, there was a medication error with one of the residents and it was addressed the same day. It was also reported to Licensing. Facility followed protocols and resident was sent to the hospital and was under observation until the next day when the resident came back.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024
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-20200626145201
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: CLUB RIVIERA
FACILITY NUMBER: 435202511
VISIT DATE: 01/03/2024
NARRATIVE
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Regarding the allegation of facility does not have sufficient food supply for emergencies, RP stated that there is not sufficient food supply for all residents during an emergency. RP also stated that he/she hasn’t observed the facility's food supply.

Based on record reviews, the facility provided two months’ worth of grocery receipts. It showed that every week, the facility gets deliveries from their supplier. Furthermore, LPA Donato was able to observe the storage area, in a different building, where the facility stores its food supplies.

Regarding the allegation of Administrator is not present at the facility enough to manage and administer the facility, RP states that the administrator manages that facility from home and only comes to the facility once every 3 or 6 months.

According to interviews, two out of two staff members mentioned that the administrator is at the facility every day. Sometimes working longer to cover a shift.

Based on observation and interviews, the department has determined that these allegations were UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

The report was reviewed, and a copy is provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2