435294143-5-19-2023-26-AS-RMAO-CTNK7S-20230712073926

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435294143
Report Date: 05/19/2023
Date Signed: 05/19/2023 08:03:10 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: 44	DATE:	05/19/2023
		UNANNOUNCED	TIME BEGAN:	10:24 AM
MET WITH:	Administrator Sam Apostol		TIME COMPLETED:	08:00 PM

ALLEGATION(S):

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Staff do not keep the facility free from pests

INVESTIGATION FINDINGS:

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On 5/19/2023, LPAs Monter and Rai and LPM Manzano conducted an unannounced complaint investigation of the above allegation.

On 5/19/2023, during today's inspection of the facility, LPAs/LPM observed 10 residents smoking and talking in the backyeard. LPAs and LPM observed swarm of approximately 40 flies forming a large or dense group under the covered patio with patio tables and chairs. Cigarette buds were observed around the cemented ground, an empty can of soda on ground. LPAs observed metled cheese and a peeled orange on the table.

An interview with Staff S1 stated the presence of the flies in the facility was due to the horses in the neighborhood.

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: 05/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023

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 4

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: 05/19/2023

NARRATIVE

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According to the reporting party (RP), on 12/6/2021, a plate of old food was on the floor and flies were observed around the food.

A random interview with residents stated that they utilized the covered patio during socialization where they had meals outside. Residents stated the staff were not observed clearing the outside patio ground and metal tables in a daily basis but if the staff do clean it will be at least once a week.

According to a insect/pest control company, Orkin, the company website states, "Common house flies are attracted to decaying organic filth such as feces and rotting meat, whereas fruit flies seek sugary substances and feed more commonly on overripe fruit, spilled soda and alcohol".[https://www.orkin.com/pests/flies/what-attracts-flies].

On 5/19/2023, LPAs and LPM conducted a tour of resident's bedrooms and common areas including kitchen were inspected. During inspection, at least 2 flies were observed in the living area and in the area in front of the exit door (between room #21 and 22) is open. LPM observed at least 1-2 flies outside the front yard.

During inspection of the facility grounds, there were a few flies observed in the front yard, side yards, front porch and around the facility perimeter except the covered patio. A horse ranch nearby the facility and is approximately 500 feet away from the facility (on the left side facing the facility) but no horses or other animals were observed during today's visit.

A random interviews with a group of 10 residents, residents stated that they have observed mice in the facility but not so much of bedbugs, except 2 residents who stated that bedbugs were in their bedrooms; however, during the inspection, presence of bedbugs were not observed, nor residents complained of bed bug bite. During interview with Administrator (ADM), ADM is aware of the presence of mice in the facility and has contracted with a pest control company to eradicate bed bugs.

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: 05/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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: 05/19/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/20/2023 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303(a) Maintenance and Operation: (a) The facility shall be in clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of mainteance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met by:	1 2 3 4 5 6 7	Administrator will submit a written plan of action on how the facility would eliminiate or irradicate the presence of flies and mice in the facility by POC date 5/20/2023
	8 9 10 11 12 13 14	Based on observation of the covered patio at the backyard has swarm of at approximately 40 flies above the 10 seated residents who were smoking. The outside table observed with an empty can soda, tables with melted cheese and a peeled orange fruit which poses an immediate Health, Safety, or Personal Rights risk to 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: 05/19/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023

LIC9099 (FAS) - (06/04)

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