<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294143
Report Date: 04/21/2022
Date Signed: 04/21/2022 03:39:39 PM


Document Has Been Signed on 04/21/2022 03:39 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA



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: 45DATE:
04/21/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Samuel ApostolTIME COMPLETED:
03:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Marybeth Donovan arrived unannounced to conduct a Case Management- Health Checks Visit. LPA met with Samuel Apostol Administrator and Yvonne Chavez Med Tech. LPA toured the facility to include the Medication Room. LPA interviewed Administrator and 4 staff and reviewed training records.

Medications are stored in a medication cart located in locked medication room. Overflow medication is stored in locked Medication Closet in the locked facility office.

LPA discussed Centrally Stored Medication Storage and Medication Training and provided a copy of Medication Training Requirements.

See attached LIC9102 Advisory Note regarding Centrally Stored Medication Storage.

LPA reviewed report with Samuel Apostol Administrator and a copy provided.




SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1