435294143-6-7-2023-26-AS-RMAO-CTNKBD-20230712074518

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435294143
Report Date: 06/07/2023
Date Signed: 06/07/2023 08:34:17 PM

Unsubstantiated

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
02/10/2023 and conducted by Evaluator Simranjit Rai

COMPLAINT CONTROL NUMBER: 26-AS-20230210140919

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: 46	DATE:	06/07/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Administrator Sam Apostol		TIME COMPLETED:	08:30 PM

ALLEGATION(S):

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Staff confiscated resident property.
Resident was assaulted by another resident.
Staff not intervene in resident on resident altercation.
Medication was not given to resident at proper time.
Resident was not fed.

INVESTIGATION FINDINGS:

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On 06/07/2023, LPAs Rai and Monter and LPM Manzano conducted an unannounced complaint investigation of the above allegations and met with Administrator Sam Apostol.

Staff confiscated resident property

Based on interview with staff, ADM stated that R1 is no longer in the facility. ADM is aware of the incident occurred on 2/22/2023. ADM stated that R1 had a cellphone but staff did not confiscate R1's phone. Staff (S1) stated they do not confiscate resident's personal belongings. ADM denied allegation that R1's cellphone was confiscated. Staff (S1) stated that R1 had a behavior where he/she thew his/her cellphone towards the staff at the facility during the incident on 2/22/2023.

Page 1 of 3. Continuation on page 2, LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 06/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2023

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 3

Control Number 26-AS-20230210140919

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: 06/07/2023

NARRATIVE

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Resident was not fed

ADM stated that R1's diet was good. ADM stated that his/her staff does not deprived R1 from not eating for 3 days rather the opposite, R1 was throwing his/her food on the floor and milk towards staff when exhibiting behaviors. ADM stated that R1's appetite was very good. Staff (S1) stated that R1 was being given meals and snacks but when exhibiting behavior the resident threw his/her food instead of consuming it.

Medication was not given to resident at proper time.

Based on allegation, the facility staff did not administer R1's medication timely manner causing his/her to have a stomach pain due to an empty stomach. ADM and staff stated that R1's medications were administered to R1 in a timely manner, nor they have any knowledge of the incident.

Resident was assaulted by another resident

Based in allegation, the resident was assaulted by another resident at the facility. Staff (S1) stated R1's roommate would complain because R1 would leave the window open and R1's roommate would be cold. The facility documented this incident occurring 2/5/2023 and 2/9/2023. During interview, S1 stated they had verbal agreements but both residents were not physical toward each other or other residents.

Staff not intervene in resident on resident altercation

ADM stated that R1 and R2 had an altercation wherein it was not witnessed. ADM stated that when R1 was in the facility, R1 had a behavior wherein he/she was not listening when being redirected. ADM stated that R1 threw milk at staff and scattered his/her clothes (clean and dirty) in his/her room and in the facility.

Page 2 of 3. Continuation on page 3, LIC9099-C

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 06/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20230210140919

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: 06/07/2023

NARRATIVE

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Based on the interviews conducted with clients and staff and based on observation and records review, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

No deficiencies cited, Exit interview conducted with Administrator, Sam Apostol.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 06/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3