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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202511
Report Date: 04/18/2024
Date Signed: 04/18/2024 04:23:39 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
04/02/2024 and conducted by Evaluator David Marrufo
COMPLAINT CONTROL NUMBER: 26-AS-20240402085640
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: 31DATE:
04/18/2024
UNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Prunella CardozoTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Illegal eviction
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Prunella Cardozo. The Department received a complaint with the above allegation on 04/02/2024. An initial complaint investigation visit was conducted on 04/10/2024.

LPA Marrufo obtained a copy of the 3-day eviction notice given to resident R1 on 04/01/2024. The eviction notice is signed by the facility Program Director (PD) and states that R1 refused to sign.

LPA Marrufo obtained a copy of an email from PD to R1’s Case Manager (CM) dated 04/01/2024. PD attached a copy of R1’s 3-day eviction and told CM that if the licensing agency rejects the 3-day eviction notice, then a 30-day eviction notice will be given to R1.

See LIC9099-C for more information. Page 1 of 2.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024
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 5
Control Number 26-AS-20240402085640
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: 04/18/2024
NARRATIVE
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During interview, Program Director (PD) stated to have delivered a 3-day eviction notice to resident R1 in person and verbally told R1 that the 3-day eviction notice was awaiting approval from the licensing agency.

LPA Marrufo obtained a copy of the 30-day eviction that PD gave to R1. The 30-day eviction states it was issued on 04/01/2024, although it is signed and dated by PD on 04/02/2024. The 30-day eviction notice states R1 refused to sign.

The 30-day eviction notice states the reasons for eviction. However, the 30-day eviction notice does not state the dates and witnesses of each reason for eviction.

Based on records review and interviews, there is preponderance of evidence to prove the alleged violation did occur. Therefore, the allegation is substantiated.

See 9099-D for deficiencies cited per the California Code of Regulations, Title 22.

This report was reviewed with Prunella Cardozo and a copy of this report and appeal rights were provided.



Page 2 of 2.



END REPORT
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024
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
04/02/2024 and conducted by Evaluator David Marrufo
COMPLAINT CONTROL NUMBER: 26-AS-20240402085640

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: 31DATE:
04/18/2024
UNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Prunella CardozoTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Facility is retaliating against resident for filling a complaint
Facility staff does not ensure client records are properly maintained
Facility withheld medication from the resident
INVESTIGATION FINDINGS:
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During interview, resident R1 stated that the facility Licensee came to R1’s bedroom and tried to take R1’s curling iron and accused R1 of smoking in R1’s bedroom.

During interview, Licensee stated to have not come into R1’s bedroom and to have never seen R1.

R1 stated that staff S1 “snapped” at R1 several times.

During interview, S1 stated to have never been disrespectful to R1. S1 stated to have never snapped at R1 and to have not observed any other staff snapping or responding angrily at R1.
LPA Marrufo obtained a copy of R1’s “History & Physical” form that the facility received from the health facility that R1 was admitted to prior to moving to the facility.

See LIC9099-C for more information. Page 1 of 2.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024
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-20240402085640
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: 04/18/2024
NARRATIVE
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LPA Marrufo obtained copies of R1’s Identification and Emergency Information Form and Admission Agreement, which both state R1 was admitted into the facility on 03/08/2024.

During interview, PD stated that R1 does not have an LIC602 Physician’s Report in R1’s resident record at the facility. PD stated that when R1 moved into the facility on 03/08/2024, PD told R1 on 03/11/2024 that R1 needed to see R1’s doctor to have an LIC602 Physician’s Report completed. PD stated R1 did not want to provide facility staff with the contact information of R1’s doctor. PD stated R1 stated the soonest R1 could schedule an appointment with R1’s doctor would be in mid-April.

During interview, R1 stated that facility staff had not asked R1 to make an appointment to complete an LIC602 Physician’s Report.

The House Rules section in R1’s Admission Agreement states on page 4, “Residents are not allowed to keep any prescribed medications or over the counter (OTC) medications in the bedroom. All medications must be stored in the facility medication room, unless otherwise instructed by doctor in writing.”

During interview, R1 stated that PD told R1 that R1 initially told R1 that R1 cannot take R1’s medication when R1 moves out of the facility because R1 did not yet have an LIC602 Physician’s Report that verified that R1 could handle medication. R1 stated that now the staff have told R1 that R1 can take R1’s medication when R1 moves from the facility.

R1 stated that staff have not kept R1 from taking medications according to doctor’s orders while R1 has been living at the facility.

During interview, PD stated that staff have not withheld medications from R1. During interview, CM stated that facility staff have always given R1 medications according to doctor’s orders.

Based on information from interviews conducted with staff, and observations made, although the allegations listed above may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are unsubstantiated. No Deficiencies were cited under California Code of Regulations Title 22. This report was reviewed with Prunella Cardozo and a copy of this report was provided. Page 2 of 2. END REPORT.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 26-AS-20240402085640
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: 04/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/25/2024
Section Cited
CCR
80068.5(c)
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80068.5 Eviction Procedures (c) The notice to quit shall state the reasons for the eviction, with specific facts supporting the reason for the eviction including the date, place, witnesses, if any, and circumstances. This requirement was not met as evidenced by:
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Licensee agrees to review any ongoing 30-day eviction notices, included R1’s 30-day eviction notice, and retract the 30-day notice if it does not include the required specific facts supporting the reason for eviction by POC date.
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Licensee did not ensure that the 30-day eviction notice given to resident R1 included specific facts supporting the reason for eviction including the date, place, witnesses, if any, and circumstances, which poses a potential safety risk to residents in care.
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 If the Licensee decides to re-issue the 30-day eviction, the licensee shall ensure that the revised 30-day eviction contains specific facts supporting the reason for eviction and submit a copy of the revised 30-day eviction to CCL by POC date.
Type B
04/25/2024
Section Cited
CCR
85068.5(b)(1)
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85068.5 Eviction Procedures (b) The licensee shall be permitted to evict a client by serving the client with a three-day written notice to quit provided that both of the following requirements have been met:
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Licensee agrees to retract the 3-day eviction notice to R1 and submit a statement of understanding of the Eviction Procedures regulations in CCL Title 22 Regulations 85068.5 and 80068.5 by POC date.
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 (1) The licensing agency has granted prior written and/or documented telephone approval for the eviction. This requirement was not met as evidenced by: Licensee did not ensure that the licensing agency had granted approval for the 3-day eviction for R1 prior to the facility serving the 3-day eviction to R1.
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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: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5