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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435294143
Report Date: 06/07/2023
Date Signed: 06/07/2023 08:35:49 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
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 AVENUETELEPHONE:
(408) 683-0229
CITY:SAN MARTINSTATE: CAZIP CODE:
95046
CAPACITY:46CENSUS: 46DATE:
06/07/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator Sam ApostolTIME COMPLETED:
08:30 PM
ALLEGATION(S):
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Unlawful Eviction
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.

Unlawful Eviction.

On 06/07/2023, Based on interview with ADM, ADM stated that facility had an outburst behavior which was out of control. The facility had to call Emergency Psychiatric Services (EPS) and 24 hour care regarding R1's uncontrolled behavioral outburst. ADM stated that EPS came to the facility 2-3 hours later wherein they took R1. R1 was admitted at EPS.



Page 1 of 2. Continuation on page 2, 9099-C.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (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 2
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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ADM stated EPS was informed that R1 has to be stable prior to returning back to the facility. ADM stated that R1's social worker and 24 hour care were aware, involved and agreed that R1 need a higher level of care and subsequently admitted to a secured facility in San Jose.

Staff (S1) stated that R1 was not picked up by EPS rather they called the Sheriff. Sheriff took R1 to Momentum Crisis Residential.

ADM stated that the facility is willing to work with their residents and with their responsible party but when a resident has an uncontrolled behavior and being disruptive in the facility, they

ADM denied allegation that R1 was illegally evicted.

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 ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (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 2