435294143-6-7-2023-26-AS-RMAO-CTNK7Q-20230712073926

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435294143
Report Date: 06/07/2023
Date Signed: 06/07/2023 08:23:47 PM

Unfounded

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
12/01/2021 and conducted by Evaluator Simranjit Rai

COMPLAINT CONTROL NUMBER: 26-AS-20211201154803

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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Resident's hygiene needs are not being met
Resident's bed was not properly maintained
Resident was unable to shower while in care
Residents medication is not given appropriately

INVESTIGATION FINDINGS:

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On 6/7/2023, LPAs Monter and Rai and LPM Manzano conducted an unannounced complaint investigation of the above allegation and met with Administrator, Sam Apostol.

On 12/1/2021, Community Care Licensing Division (CCLD) received a complaint with the above allegations.

On 12/9/2021, the initial investigation visit was conducted. The facility interior and exterior including the TV room, shower rooms, resident rooms, hallways, kitchen, laundry room, smoking area, and backyard was inspected. Medication Audit for R1 - R2 was conducted and MedTech on duty was interviewed. The facility provided a copy of facility's resident roster, staff schedule, resident shower log, visitor log sign-in sheet, and R1-R2s medication log.

Page 1 out of 3, see continuation on LIC 9099-C (Page 2).

Unfounded

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-20211201154803

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 left soiled
During previous inspection 5/19/2023, an interview with staff and ADM stated that bedsheets are changed every once a week except when a resident has an accident such incontinence. LPA inspected R1's bedroom #19, R1's linen had dry urine stain & R2's pillow had dry blood due to severe acne. R1 is incontinent.
During today's visit, staff stated they were in the middle of assisting residents and changing everyone's linens during our inspection. LPAs and LPMs did not observe staff who were soiled.

Resident's hygiene needs are not being met
According to the allegation, the residents were seen strangely filthy at the facility. During today's tour of the facility , residents were observed during meal time, and around the property. There were no complaints regarding the staff not attending to their needs. The residents were observed not to be disheveled. LPAs and LPM observed the residents to be wearing clothes without stains and unintentional rips. During interview with residents, all 4 residents were independent with their grooming and asked staff for help if they need it.

During inspection, there was an odor in Room #12. The resident (R1) does not get up and resident is incontinent with bladder. According to the ADM, they were cleaning the resident and the room and they will follow up with social worker. The resident refuses to wear incontinent pad and a plastic cover has been placed over the mattress.

Resident's bed was not properly maintained
LPAs randomly inspected residents bedrooms. Residents' were also interviewed. Residents provided responses that bedsheets are washed during different times of the week. During today's inspection, 6/7/2023, the resident rooms were made with blankets tucked in and was clean of dirt and debris.

Resident was unable to shower while in care
During today's inspection, 3 Out of 4 residents interviewed stated they take a shower themselves and 1 out of the 4 residents interviewed stated they need help while taking a shower. All 4 residents interviewed stated the staff administer the medication during scheduled time. During inspection, LPAs and LPM observed the shower room to be unlocked and a schedule of the resident showers was posted outside.

Page 2 out of 3, see continuation on LIC 9099-C (Page 3).

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-20211201154803

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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Page 3 out of 3.

Residents medication is not given appropriately
ADM and staff stated that R1's medications were administered to R1 in a timely manner, nor they have any knowledge of the incidents where medication was not given.

The Department has completed the investigation of the above allegations. Based on interviews conducted and record reviews, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.

No deficiencies cited, Exit interview conducted with Administrator, Sam Apostol and a copy of the report was provided.

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)

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