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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435294143
Report Date: 07/17/2020
Date Signed: 07/20/2020 02:37:15 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
03/17/2020 and conducted by Evaluator Maria Kamara
COMPLAINT CONTROL NUMBER: 26-AS-20200317123434
FACILITY NAME:SOUTH COUNTY RETIREMENT HOME INC.FACILITY NUMBER:
435294143
ADMINISTRATOR:APOSTOL, SAMUEL C.FACILITY TYPE:
740
ADDRESS:460 CHURCH AVENUETELEPHONE:
(408) 683-0229
CITY:SAN MARTINSTATE: CAZIP CODE:
95046
CAPACITY:46CENSUS: 43DATE:
07/17/2020
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH: Sam ApostleTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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8
9
Facility neglect resulted in resident falling and sustaining a fractured hip

INVESTIGATION FINDINGS:
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13
On 7/17/2020, Licensing Program Analysts (LPAs) Maria Kamara and Steve Nguyen conducted an unannounced subsequent complaint investigation via tele-conference call with the facility. LPA spoke with Sam Apostle, Licensee/Administrator who was informed of the purpose for the call, which was to deliver finding on the above allegation. LPA Maria informed Sam Apostle that due to the current COVID-19 "shelter in place" the Department is currently conducting tele-conference call in the place of an on-site complaint investigation.

On 3/24/2020, at 8:56AM, a 10-day initial complaint investigation tele-conference video call was completed.

R1’s documents pertaining to the complaint were obtained. The complaint was referred to the (IB) Investigation Bureau for investigation.

See continuation Pg.2 of LIC9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: George NwaforTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Maria KamaraTELEPHONE: (650) 388-2295
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2020
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-20200317123434
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: SOUTH COUNTY RETIREMENT HOME INC.
FACILITY NUMBER: 435294143
VISIT DATE: 07/17/2020
NARRATIVE
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Pg.2

On 4/28/2020, the Department’s (IB) Investigation Branch conducted interviews with (RP)Reporting Party. On 5/1/2020 a face to face interview was conducted with resident (R1) at the Gilroy Healthcare and Rehabilitation were R1 was currently admitted. On 5/1/2020, 5/5/2020, 5/8/2020 & 5/12/2020, staff, administrator, residents and family member were interviewed. Interviews with staff indicated that R1 is able to walk and handle her (ADL's) and hygiene needs by herself. Facility conducts status checks every two hours on residents.
On 4/28/2020, contact with the Santa Clara Sheriff’s Department records office indicated a 911 call was received but only Paramedics had responded at the facility. No case number or investigation was located on this investigation.

On 4/28/2020, IB's investigation interview with (RP)Reporting Party stated that there has not been any prior issues with the facility and there appeared to be sufficient caregivers on duty to oversee residents. (RP) Reporting Party stated that R-1 was capable of performing and handle her (ADL's) activity of daily living and hygiene needs by herself.

On 5/7/2020 Medical Records for (R1) were received via mail from St. Louise Regional Hospital.

Based on available information gathered, the Department’s (IB) Investigations Branch, observations, interviews with R1, staffs, residents, agency staffs, family member, Santa Clara Sheriff’s Department and review of supporting documents obtained during the cause of the investigation, the preponderance of evidence standard has been met therefore the above allegation is found to be UNSUBSTANTIATED meaning 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, therefore the allegation is dismissed.

Exit interview was conducted with Licensee/Administrator, Sam Apostle. No deficiencies were cited as a result of this complaint investigation.

LPA Maria informed Licensee/Administrator, Sam Apostle that a copy of the signed LIC9099 by LPA Maria will be sent to the facility for signature via email facility address:: apostolsamuel58@gmail.com and returned to LPA Maria.
SUPERVISOR'S NAME: George NwaforTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Maria KamaraTELEPHONE: (650) 388-2295
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2020
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
CCLD Regional Office, 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
03/17/2020 and conducted by Evaluator Maria Kamara
COMPLAINT CONTROL NUMBER: 26-AS-20200317123434

FACILITY NAME:SOUTH COUNTY RETIREMENT HOME INC.FACILITY NUMBER:
435294143
ADMINISTRATOR:APOSTOL, SAMUEL C.FACILITY TYPE:
740
ADDRESS:460 CHURCH AVENUETELEPHONE:
(408) 683-0229
CITY:SAN MARTINSTATE: CAZIP CODE:
95046
CAPACITY:46CENSUS: 43DATE:
07/17/2020
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Sam ApostleTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff did not report incident to resident's responsible party in a timely manner.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 7/17/2020, Licensing Program Analyst (LPA) Maria Kamara conducted an unannounced subsequent complaint investigation via tele-conference call with the facility. LPA spoke with Sam Apostle, Licensee/Administrator who was informed of the purpose for the call, which was to deliver finding on the above allegation. LPA Maria informed Sam Apostle that due to the current COVID-19 "shelter in place" the Department is currently conducting tele-conference call in the place of an on-site complaint investigation.

On 3/24/2020, at 8:56AM, a 10-day initial complaint investigation tele-conference video call was completed.

On 3/24/2019, LPA Maria reviewed four staffs and three sidents’ records. Five staffs were interviewed. Copies of R1's documents pertaining to the complaint were obtained.

See continuation Pg.2 of LIC9099C
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: George NwaforTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Maria KamaraTELEPHONE: (650) 388-2295
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2020
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-20200317123434
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: SOUTH COUNTY RETIREMENT HOME INC.
FACILITY NUMBER: 435294143
VISIT DATE: 07/17/2020
NARRATIVE
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3
4
5
6
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8
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Pg.2

On 6/5/2020, at 12:30PM, during the course of the investigation, LPA Maria interviewed four staffs and the Administrator. Four staffs and the Administrator stated that R1 is currently admitted at the hospital for medical reasons. Staffs stated that their duties include (ADL's) activity of daily living and meets the residents hygiene needs. Staffs stated that R-1 is able to walk and handle her (ADL's) and hygiene needs by herself. Three staffs and the administrator stated that a report was faxed to CCL office in a timely manner and that the facility staff seek medical attention for the residents as needed. Five out of five staffs interviewed stated that the facility does not know or have any contact information of R1's relative (sister) and that all incidents of R1 is reported to the case manager who is responsible to inform the relative. Staffs (S1 to S5) denied the allegation listed above.

On 6/5/2020, Staff (S5) interviewed stated that on 3/9/2020 between the hours of 8:00AM and 8:30AM, she called and informed responsible party of R1's incident and that responsible party had gone to visit R1 at the hospital and that responsible party had come to the facility after visiting R1 to inform of R1's medical condition. Staff S5 denied the allegation listed above.

On 6/5/2020 at 1:40PM, LPA had a telephone call interview with (RP) Reporting Party. Reporting Party stated that there has not been any prior issues with the facility and there appeared to be sufficient caregivers on duty to oversee residents. RP stated that she was concerned that the incident of R1 was not reported to the appropriate representatives in a timely manner. RP stated that R1 has been living at the facility since August of 2006 and that R1 likes the facility.



See continuation Pg. 3 of 3 of LIC9099C.
SUPERVISOR'S NAME: George NwaforTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Maria KamaraTELEPHONE: (650) 388-2295
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2020
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 26-AS-20200317123434
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: SOUTH COUNTY RETIREMENT HOME INC.
FACILITY NUMBER: 435294143
VISIT DATE: 07/17/2020
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
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14
15
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Pg.3

Based on available information gathered, LPA's inspection, observations, interviews with staffs, residents and agency staff, records review and copies of supporting documents obtained during the cause of the investigation, on the above complaint allegation, the preponderance of evidence standard has been met therefore the above allegation is found to be UNFOUNDED meaning that the allegation is false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. No deficiencies were cited as a result of this complaint investigation.

Exit interview was conducted with Licensee/Administrator, Sam Apostle. No deficiencies were cited as a result of this complaint investigation. LPA Maria informed Licensee/Administrator, Sam Apostle that a copy of the signed LIC9099 by LPA Maria will be sent to the facility for signature via email facility address:: apostolsamuel58@gmail.com and returned to LPA Maria.
SUPERVISOR'S NAME: George NwaforTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Maria KamaraTELEPHONE: (650) 388-2295
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2020
LIC9099 (FAS) - (06/04)
Page: 5 of 5