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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294143
Report Date: 11/28/2020
Date Signed: 12/01/2020 04:40:55 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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:
11/28/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Administrator Samuel ApostolTIME COMPLETED:
01:44 PM
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LPA Steve Nguyen and LPM Brenda Chan conducted a TA with Administrator Samuel Apostol. The TA was conducted in order to help facilitate and assist the facility be in compliance with the latest Covid protocols according to CDC, PHD, and CCLD guidelines.

Per Administrator:

Census 44/ Staffing is good and there's ample PPE. Mass testing was conducted on 11/25/2020 for all staff (12) and residents (44). Facility is awaiting results and will fax line list to Department when results are in. PHD is notified as of 11/24/2020. Facility have had training on 11/25/2020 on proper PPE usage and COVID protocols from RN @ Saint Patrick.

Staff was exposed outside of the facility to COVID on 11/20/2020. Tested on 11/25/2020 and results came back on 11/25/2020 showing a positive COVID result. Last day of work was 11/20/2020 and staff is currently home, self isolating.

Facility has isolation room prepared for COVID resident and room has its own bath.

END OF REPORT

SUPERVISOR'S NAME: George NwaforTELEPHONE: (408) 324-2116
LICENSING EVALUATOR NAME: Steve NguyenTELEPHONE: (650) 676-0051
LICENSING EVALUATOR SIGNATURE:

DATE: 11/28/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2020
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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