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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294143
Report Date: 05/19/2023
Date Signed: 05/19/2023 07:53:03 PM


Document Has Been Signed on 05/19/2023 07:53 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



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: 44DATE:
05/19/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:24 AM
MET WITH:Administrator Sam ApostolTIME COMPLETED:
08:00 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
On 5/19/2023, LPAs Monter and Rai and LPM Manzano were in the facility to do an unannounced complaint investigation.

During interview with staff (S1), LPAs observed S1 preparing residents' medication in advance for Friday evening, and weekend. The medications in the medication room were prepped ahead of time, more than 24 hours. S1 stated that they started practice of prepping medications since pandemic. The resident's medication was delivered from the pharmacy in bubble pack and facility staff were transferring to small brown packets.

LPAs/LPM interviewed Administrator who stated that the medication should only be prepared 24 hours in advance and anything more is not acceptable.

Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D.

This report was reviewed with Administrator Sam Apostol and a copy of the report was provided. Appeal Rights was provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2023
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 2


Document Has Been Signed on 05/19/2023 07:53 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/26/2023
Section Cited
CCR
87465(h)(5)

1
2
3
4
5
6
7
Incidental Medical and Dental Care (h)(5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met by:
1
2
3
4
5
6
7
Administrator will submit a written plan of action on how the facility would prepare the medication in a timely manner and keep the medication in original bubble pack provided by the pharmacy by POC date 5/26/2023.
8
9
10
11
12
13
14
Based on interview and observation, the administrator did not comply by storing resident medication in small brown envelopes 4 days in advance which poses a potential Health, Safety, or Personal Rights risk to persons in care
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2