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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202511
Report Date: 03/22/2024
Date Signed: 03/22/2024 01:27:18 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
03/14/2024 and conducted by Evaluator Manuel Monter
COMPLAINT CONTROL NUMBER: 26-AS-20240314124942
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:
03/22/2024
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Program Director (PD) Maria Canizales.TIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff does not provide resident privacy prior to entering resident's room.
INVESTIGATION FINDINGS:
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Licensing Program Analyst Manuel Monter conducted an unannounced complaint investigation visit and met with Program Director (PD) Maria Canizales and explained the purpose of the visit.

On March 14, 2024, the Department received a complaint alleging Staff does not provide resident privacy prior to entering resident's room. It has been alleged staff members do not knock when enter resident bedrooms at night during bedtime checks.

On March 22, 2024, Licensing Program Analyst interviewed 5 residents, R1-R5. 4 Out of 5 residents stated staff knock before entering their bedrooms. 1 Out of 5 residents interviewed stated, a staff member opened the door to his/her room at night without knocking.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024
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 3
Control Number 26-AS-20240314124942
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: 03/22/2024
NARRATIVE
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LPA interviewed staff member, S1. Staff S1 stated, he/she just opens the door and checks the residents inside and see if they are breaking the rules. S1 stated he/she usually never knocks. Staff S1 confirmed that he/she did open a residents bedroom door without knocking. S1 stated he/she had a conversation with PD, who gave him/her a verbal warning and will knock from now on.

LPA interviewed Program Director (PD). PD stated, staff S1 went inside and opened the door and did not knock before entering. PD stated a resident notified PD the following day. PD stated she gave staff S1 a verbal warning and stated staff needs to knock before entering.

The Department has investigated the above allegation. Based on records reviewed, and interviews conducted, the preponderance of evidence standard has been met. Therefore, the Department found the above allegation to be SUBSTANTIATED.

A Deficiency is being cited. See LIC 9099-D. Exit interview conducted with Program Director (PD) Maria Canizales. and a signed copy of this report was provided along with appeal rights.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 26-AS-20240314124942
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: 03/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/29/2024
Section Cited
CCR
80072(a)(1)
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80072 Personal Rights (a)(1) To be accorded dignity in his/her personal relationships with staff and other persons

This requirement was not met as evidenced by;
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ADM stated she will conduct a personal rights training for staff. ADM stated she will send documentaion the training has taken place to LPA by POC date.
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Based on interviews conducted, staff S1 admitted to opening a residents bedroom door without knocking. PD stated S1 was given a verbal warning and will knock residents doors before entering. This poses/posed a potential health, safety or 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: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3