435294143-11-22-2022-26-AS-KHOS-CM3PZG-20221213104530

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435294143
Report Date: 11/22/2022
Date Signed: 11/22/2022 04:47:28 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
02/10/2022 and conducted by Evaluator Ryker Heberle

COMPLAINT CONTROL NUMBER: 26-AS-20220210171405

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: 45	DATE:	11/22/2022
		UNANNOUNCED	TIME BEGAN:	03:50 PM
MET WITH:	Ivonne Chavez		TIME COMPLETED:	04:55 PM

ALLEGATION(S):

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Resident sustained an unwitnessed fall, causing a fracture.
Medical attention for resident was not sought in a timely manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced complaint inspection to deliver the findings on the above allegations. LPA met with facility Medical Technician Ivonne Chavez (S1). Administrator Samuel Aposto (Admin) was unable to attend the inspection. Admin gave S1 permission to sign and review the report on his behalf.

On 11/22/2021, a resident (R1) was discharged from the hospital and referred to a home health agency. The discharge medical records indicate that R1 had difficulty walking, impaired mobility, and issues with activities for daily living. R1 was assessed by home health and was determined to need support during transfers. R1 was noted to have fall precautions put in place, and was noted to only walk while supervised. Witnesses reported that during visits, they attempted to locate staff to provide this information, but were unable to find staff within the facility. During interviews with staff members, staff stated that R1 was able to ambulate by himself, but didn't because he was "lazy."

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022

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 4

Control Number 26-AS-20220210171405

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: SOUTH COUNTY RETIREMENT HOME INC.	FACILITY NUMBER: 435294143
	VISIT DATE: 11/22/2022

NARRATIVE

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Staff reported that R1 had a history of falls but no prevention plan. R1 had only one documented fall at the facility, with the reason for emergency evacuation to the hospital being listed as "weakness." R1 was diagnosed with a fractured femur at the hospital. Information provided by the facility did not match with the transcript of the 911 call nor the ambulance records. Staff that reportedly assisted with the fall claimed that they did not work on the day that the fall took place. Administrative and medical staff at the facility provided information regarding the fall, but were unable to remember the fall when re-interviewed. Administrative and medical staff reported that R1 needed a higher level of care than they were able to provide.

On an unknown date, facility staff member (S1) witnessed R1 on their bedroom floor and assisted them up. S1 documented that R1 was unable to move their hand and was unable to sit. A separate staff member (S2) reported that they were concerned about R1 because R1 was not eating. S2 determined that R1 needed medical attention, but R1 refused to go to the hospital. R1 was sent to the hospital 2 days later because they were not able to move, sit, or eat. Ambulance records indicate that R1 had been weak for 2 days. The information reflects that staff were aware and were concerned that R1 needed medical attention, but did not send him to the hospital in a timely manner.

The Department has conducted an investigation of the above allegations. Based on interviews and records review, the preponderance of evidence standard has been met. Therefore, the Department found the above allegations to be SUBSTANTIATED. Deficiencies are being cited. See LIC 9099-D.

Exit interview conducted with Medical Technician Ivonne Chavez. A copy of this report, along with the facility's appeal rights were provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 4

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
02/10/2022 and conducted by Evaluator Ryker Heberle

COMPLAINT CONTROL NUMBER: 26-AS-20220210171405

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: 45	DATE:	11/22/2022
		UNANNOUNCED	TIME BEGAN:	03:50 PM
MET WITH:	Samuel Apostol		TIME COMPLETED:	04:55 PM

ALLEGATION(S):

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Wrongful Eviction

INVESTIGATION FINDINGS:

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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannoucned complaint inspection to deliver the findings on the above allegations. LPA met with facility Medical Technician Ivonne Chavez (Admin).

In review of facility records, it was indicated that R1 was taken to the hospital from December 2021 to Febraury 2022 due to the fact that R1 was not independant. R1 was transferred to skilled nursing shortly thereafter. In interview with a representative (W1) from an organization relevant to R1's placement, W1 said that there are no records of R1 being evicted from the facility. W1 stated that their records indicate that R1 was formally discharged from the facility due to his hospitialization.

The Department has investigated the above allegations. Based on interviews conducted and documents reviewed, the Department found the above allegations to be UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. Exit interview was conducted with Medical Technician Ivonne Chavez and a copy of the signed report was provided.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022

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 4

Control Number 26-AS-20220210171405

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: SOUTH COUNTY RETIREMENT HOME INC.	FACILITY NUMBER: 435294143
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/22/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/23/2022 Section Cited CCR 87463(a)	1 2 3 4 5 6 7	87463 - Reappraisals - (a) The pre-admission appraisal shall be updated... to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical... condition. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee to submit updated written procedures for staff to reappraise residents upon return from the hospital and upon emerging changing health conditions by POC due date
	8 9 10 11 12 13 14	Based on interviews and records review, the facility did not update R1's care plan when it became evident that R1 was a fall risk, resulting in fracture. This posed an immediate threat to the health and safety of residents in care	8 9 10 11 12 13 14
Type A 11/23/2022 Section Cited CCR 87465(g)	1 2 3 4 5 6 7	87465 - Incidental Medical and Dental Care - (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health... This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee to conduct trainings with staff to assist with identifiying circumstances in which calling emergency services is necessary and provide proof of scheduling by POC due date
	8 9 10 11 12 13 14	Based on interviews and records review, the facility did not contact 911 until two days after R1's injury that resulted in fracture. This posed an immediate threat to the health and safety of residents in care.	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022

LIC9099 (FAS) - (06/04)

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