435294143-6-7-2023-26-AS-RMAO-CTNK7P-20230712073926

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435294143
Report Date: 06/07/2023
Date Signed: 06/07/2023 08:27:15 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
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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Staff do not properly maintain the facility

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 bin.

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

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 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 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.

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: 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
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: 3 of 3