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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294143
Report Date: 06/22/2023
Date Signed: 06/22/2023 05:16:24 PM


Document Has Been Signed on 06/22/2023 05:16 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: 46DATE:
06/22/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Administrator Sam ApostolTIME COMPLETED:
05:00 PM
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LPAs Rai and Monter and LPM Manzano conducted an unannounced case management visit-plan of correction (POC) visit. Met with Administrator Sam Apostol.

The purpose of this visit is to ensure that the facility administrator and staff are adhering to the Plan of Corrections submitted to the department as a result of citations and deficiencies issued on the following inspection/investigation visits:

LPAs and LPM also met with 3 Rehab Counselors from Santa Clara County Behavioral Health (SCCBH). SCCBH has 36 residents at this facility. SCCBH counselors, LPAs/LPM and Administrator had a meeting wherein the importance of 'collaboration and accountability'' between the facility and SCCBH is vital to ensure that needs and supervision of residents in the facility are discussed and individual assessment or plan of care is in place. SCCBH agreed to initiate 'care conference' quarterly and as needed to note significant changes in physical, medical, mental and social condition of each resident. Administrator will reach out to case manager/social worker of residents which are not under SCCBH. SCCBH joined LPAs/LPM during tour of the facility and random checks of residents' bedrooms. Administrator agreed and understood that collaboration with SCCBH and other agencies is important.

Based on today's inspection visit, the Administrator and staff have corrected all of the above citation/deficiencies. POC clearance are issued and provided to Mr. Apostol.


No deficiencies cited during today's visit.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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