435294143-10-6-2020-26-AS-KHOS-BVGNDQ-20201118092244

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435294143
Report Date: 10/06/2020
Date Signed: 10/06/2020 03:56:58 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
09/28/2020 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20200928181029

FACILITY NAME:	SOUTH COUNTY RETIREMENT HOME INC.		FACILITY NUMBER:	435294143
ADMINISTRATOR:	APOSTOL, SAMUEL C.		FACILITY TYPE:	740
ADDRESS:	460 CHURCH AVENUE		TELEPHONE:	(408) 683-0229
CITY:	SAN MARTIN	STATE: CA	ZIP CODE:	95046
CAPACITY:	46	CENSUS: 44	DATE:	10/06/2020
		UNANNOUNCED	TIME BEGAN:	10:31 AM
MET WITH:	Samuel Apostol		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff do not allow resident to have phone calls.
Staff do not stafegaurd resident's personal belongings.
Staff do not treat resident with respect.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) David Marrufo and Steve Nguyen conducted an unannounced complaint investigation visit over Facetime video conference call and met with Administrator Samuel Apostol. The visit was conducted over Facetime due to the ongoing COVID-19 Shelter-in-Place order.

During the complaint investigation visit on 10/05/2020, LPAs Marrufo and Nguyen interviewed residents R1-R10 and staff S1-S2. LPAs Marrufo and Nguyen also obtained a copy of the resident roster.

See LIC9099-C for more information. Page 1 of 2.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: George Nwafor	TELEPHONE: (408) 324-2116
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2020

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 2

Control Number 26-AS-20200928181029

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: 10/06/2020

NARRATIVE

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During visit on 10/06/2020, LPAs Marrufo and Nguyen requested the following records for residents R1, R6, R7, R10, R11, and R12: Physician's Report, Admission Agreement, LIC621 Client/Resident Personal Property and Valuables, and House Rules. Review of resident records indicate that R1, R6, R7, R10, R11, and R12 did not have any valuables claimed on their signed LIC621 Client/Resident Personal Property and Valuables forms. LPAs Marrufo and Nguyen also interviewed staff S3-S6 as well as Administrator Apostol and were given a virtual tour of the facility and observed the facility pay phone that is available for residents to use.

During interviews, ten out of ten residents and six out of six staff reported to have never observed a staff not allow a resident to make or receive phone calls. Staff and residents reported that residents can use the pay phone to make and receive calls and if residents do not have coins for the pay phone, then staff will make the office phone available for them to use or give them coins. Ten out of ten residents and six out of six staff reported during interviews to have never observed a staff treat a resident with disrespect.

During interview, R12 stated to have had personal clothing gone missing. However, R12's Admission Agreement states that resident clothing "must be declared upon admission filling out an inventory sheet, or signing a waiver stating they choose not to fill out the inventory sheet" and R12 initialed a statement declining to have personal items inventoried. In addition, four out of six interviewed staff reported that residents will report clothing missing while staff are doing their laundry for them. Moreover, Rule 4 of the facility House Rules indicates "For resident’s convenience and comfort, selected items of personal furniture and personal possessions are welcome. We suggest one doesn’t bring in anything of extreme value such as diamond and gold for they can get lost."

Based on information from interviews conducted with staff, and records reviewed, although the allegations listed above may have happened or is 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 Administrator Samuel Apostol. A copy of the report will be sent to him to be signed and returned to CCL. Page 2 of 2.

SUPERVISOR'S NAME: George Nwafor	TELEPHONE: (408) 324-2116
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 2