435294143-6-7-2023-26-AS-RMAO-CTNKAD-20230712074347

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435294143
Report Date: 06/07/2023
Date Signed: 06/07/2023 08:39:28 PM

Unsubstantiated

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
07/18/2022 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20220718115833

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:	DATE:	06/07/2023
		UNANNOUNCED	TIME BEGAN:	06:25 PM
MET WITH:			TIME COMPLETED:	08:30 PM

ALLEGATION(S):

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Staff did not report incident involving resident
Resident sustained injury while in care
Staff did not prevent resident from attacking another resident
Staff are not providing a comfortable envionment for resident

INVESTIGATION FINDINGS:

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On 6/7/2023, Based on interview with ADM and Staff (S1), R1 and R2 had a verbal and physical altercation on 07/13/2022 regarding R2's watch. R1 grabbed R2's watch causing a cut on his/her right arm.
ADM stated that LIC624 was submitted to CCLD on 7/14/2022.

ADM stated that R2's responsible party was notified was notified of this incident according to ADM. Based on record review, CCLD received an incident report of this incident between R1 and R2.

Based on investigation, R2 did sustained an injury during an unwitness altercation with R1. ADM stated that first aid was applied but does not require hospitalization.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	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)

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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
07/18/2022 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20220718115833

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:	DATE:	06/07/2023
		UNANNOUNCED	TIME BEGAN:	06:25 PM
MET WITH:	Sam Apostol		TIME COMPLETED:	08:30 PM

ALLEGATION(S):

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Facility faling to safeguard residents property

INVESTIGATION FINDINGS:

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On 06/07/2023, the Department conducted investigation of the facility and staff on the alleged complaint. Note; a similar alligation, complaint 5/18/23, is being investigated as well.

Facility faling to safeguard residents property

On 06/07/2023, Based on investigation, LPM interviewed Staff (S1), S1 stated that he/she works every Sunday, Tuesday and Wednesday as one of the laundry staff. S1 stated that he/she along with other two staff responsible for the laundry are labeling residents' clothings. S1 stated that there are clothes in the laundry room wherein with no labels.

During inspection of the laundry room along with S1, LPM noted that there were more than 20 men and females clothes from sweater, tee-shirts, and pants with no labels.
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Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	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: 2 of 4

Control Number 26-AS-20220718115833

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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On 06/07/2023, ADM was interviewed. ADM also acknowledge that staff were instructed to label residents' clothing. ADM acknowledged awareness of missing items being reported by residents.

On 06/07/2023, a random interviews with residents were conducted wherein R1 to R3 reported that they had missing items and clothes. R1 stated that they were asked by staff to put labels on their clothes but missing items continue to be an issue at the facility. R1 stated that later on staff will let her/him know that the missing items were found.

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.

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SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	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: 3 of 4

Control Number 26-AS-20220718115833

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 B 06/07/2023 Section Cited CCR 87217(b)	1 2 3 4 5 6 7	87217(b) Safeguards for Resident Cash, Personal property and valuables: (b) Every facility shall take appropriate measures to safeguard ...personal property and valuables which have been entrusted to the licensee or facility staff. This requirement is not met evidence by:	1 2 3 4 5 6 7	Administrator stated will send memo to responsilbe parites to label new items they bring to facility. Make sure the residents cloths are labeled. And will submit plan action by June 12 2023 to safeguard residents belongings.
	8 9 10 11 12 13 14	During investigation on 5/19 and 6/7, staff and residents were interviewed and acknowledged missing items such as clothing. LPAs and LPM observed on 5/19 and 6/7 residents' clothing with no name or labels in the laundry room. This pose a potential health, safety and personal rights risk.	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: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	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)

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