435294143-6-7-2023-26-AS-RMAO-CTNK98-20230712074154

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435294143
Report Date: 06/07/2023
Date Signed: 06/07/2023 08:31:40 PM

Substantiated

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
04/22/2022 and conducted by Evaluator Simranjit Rai

COMPLAINT CONTROL NUMBER: 26-AS-20220422141525

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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Facility in disrepair

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.

During complaint investiagtion on 05/19/23, LPA toured the faciltiy and observed cigarette buds scattred in the front yard and backyard smoking area. Broken chair was observed in the front yard. LPAs and LPM observed broken blinds in residents' rooms. LPA Monter observed the floor of R1's room #5 to have a slight indentation directly at the entrance which may pose as a tripping hazard for the resident.

During today's complaint investigation, LPA's observed broken chairs and appliances (stove) in the front yard. The garbage bin in the front yard was not covered, exposing the garbage which attrached a swarm of 10-12 flies to the container. LPAs and LPM observed a pile of flattened cardboard boxes next to the garbage pin.

Page 1 of 2. Continuation, see page 2, LIC9099-C

Substantiated

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 7

Control Number 26-AS-20220422141525

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/07/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/08/2023 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include ... procedures for the safety and well-being of residents, employees and visitors. This requirement is not being met evidenced by:	1 2 3 4 5 6 7	Administrator will clean the facility and submit a written plan on keeping the facility clean, safe, sanitary and in good repair by POC date.
	8 9 10 11 12 13 14	Based on observation and interviews, multiple areas of cigarette buds found on floor, broken chairs and appliances at the front area, multiple areas with swarms of flies, including front door& smoking area which poses an immediate threat to the Health, Safety and Personal Rights risk to the persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

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 appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 7

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
04/22/2022 and conducted by Evaluator Simranjit Rai

COMPLAINT CONTROL NUMBER: 26-AS-20220422141525

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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Facility staff threaten to evict resident
Facility staff yell at resident

INVESTIGATION FINDINGS:

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On 6/7/2023, LPAs Rai and Monter and LPM Manzano conducted inspection/investigation of the above allegation.

Facility staff threaten to evict resident

On 06/07/2023, ADM denied allegation that staff threatened residents to be evicted. ADM stated that they have a few of residents who are not paying their monthly rent but these residents have not been evicted because ADM has a heart to provide them shelter.

During an interview with a residents (R1) who stated that staff threatened them with eviction if they violated house rules or did anything deprolable. Other residents were also interviewed (R2 to R6) who stated that they were not threatened with eviction at any time during their stay at the facility.

Page 1 of 2. Continuation, See 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: 3 of 7

Control Number 26-AS-20220422141525

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 2 of 2.

On 06/7/2023, Based on interviews with residents (R1 to R11), 10 Out of 11 residents stated that they do not require assistance in showering except for 1 resident (R1) who requires assistance. Staff stated that they assist residents if they requested. R1 was interviewed wherein he/she said that he/she needs assistance in showering and is receiving assistance from two staff (S1 and S2).

Facility staff yell at resident

On 06/07/2023, Based on interviews with residents (R1 to R7), 7 Out of 11 residents stated that staff did not yell at them, and the other 4 residents (R8 to R11) stated that staff yell at them when they smoke at night and make the fire alarm goes off by the ADM.

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 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)

Page: 4 of 7

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
04/22/2022 and conducted by Evaluator Simranjit Rai

COMPLAINT CONTROL NUMBER: 26-AS-20220422141525

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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Facility not following admission agreement
Facility staff not assisting resident with showering

INVESTIGATION FINDINGS:

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On 06/07/2023, LPAs Rai and Monter and LPM Manzano investigated the above allegation and met with Administrator Sam Apostol.

Facility not following admission agreement
On 06/07/2023, Based on interview with ADM, ADM stated that R1's admission agreement has not changed, nor they have increase his/her monthly rent. ADM stated that R1 is under SSI. ADM stated that R1 has not been paying his/her montly rent and owed the facility for more than a year.

ADM stated that although R1 was not paying rent, the facility has not issued an eviction letter to R1. R1 is currently residing at the facility. ADM stated that they are following their admission agreement with R1 providing his/her care and supervision. ADM stated that they addressed non-payment of rent with Community Solutions.
Page 1 of 2. Continuation, see page 2, LIC9099-C

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: 5 of 7

Control Number 26-AS-20220422141525

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 2 of 2.

Facility staff not assisting resident with showering

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.

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)

Page: 6 of 7

Control Number 26-AS-20220422141525

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 2 of 2.

LPAs and LPM continued to see cigarette buds scattered in the front yard and backyard smoking area. The wood on the handrails at the front of the facility leading to the front door was brittle and worn out. LPM observed rotten red onion near the cardboard boxes which was not properly disposed and attraced a swarm of files. During today's inspection, LPA Monter observed the floor of R1's room #5 uneven and unbalanced at the entrance.

The Department has received an allegation prior to this complaint on 12/1/2021 where the allegation stated staff did not properly maintain the facility. The Administrator will complete a Plan of Correction which will address both deficiencies.

Based on interviews and observation/inspection of the facility, the preponderance of evidence standard has been met therefore the above allegations is found to be SUBSTANTIATED.

Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 9099-D.
This report was reviewed with Administrator Sam Apostol and a copy of the report was provided. Appeal Rights 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)

Page: 7 of 7