435294143-4-30-2025-26-AS-KHOS-DK2HVC-20250729063144

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435294143
Report Date: 04/30/2025
Date Signed: 04/30/2025 03:18:10 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
04/22/2025 and conducted by Evaluator Christine Kabariti

COMPLAINT CONTROL NUMBER: 26-AS-20250422165928

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:	04/30/2025
		UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Samuel Apostol and Ivonne Chavez		TIME COMPLETED:	03:20 PM

ALLEGATION(S):

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Facility staff violated resident's personal rights

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to open the initial complaint investigation. LPA met with Administrator Samuel Apostol and Office Manager Ivonne Chavez.

On 04/22/2025, the Department received the complaint. On 04/30/2025, the initial complaint investigation was conducted. Documents were obtained to include the staff schedule, resident roster, and resident (R1)’s physician’s report, appraisal/needs and services plan, identification and emergency contact information, progress notes, and county contract.

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Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Kabariti
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2025

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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Control Number 26-AS-20250422165928

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: 04/30/2025

NARRATIVE

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It was alleged that when resident (R1) returned from the hospital, R1’s room looked different than how he/she left it. It was alleged that staff went through resident (R1)’s bedroom, threw R1’s shoes over the fence outside of R1’s bedroom, and threw away R1’s dry foods inside his/her bedroom. It was also alleged that staff had taken R1’s jacket and new shoes.

A witness (W1) was interviewed. Based on interview, it was stated that R1 had only reported that his/her items were missing to W1, but denied observing staff remove these items from R1’s bedroom. W1 was unable to provide proof that the items were taken from the staff.

3 staff members were interviewed. Based on staff interview, it was stated that on 04/10/2025 staff needed to remove items from R1’s bedroom as staff observed expired and molded food inside R1’s personal refrigerator that was purchased by the Administrator. It was stated that R1 also had items that are not allowed to be stored in the resident rooms to include cleaning supplies, scissors, and tools. For the resident’s safety, staff talked to R1 about the items that needs to be removed in which R1 began to get verbally aggressive towards the staff. Due to R1’s aggression, law enforcement was called and R1 was transported to the hospital to be evaluated.

Staff stated that the only items that was removed was the dry foods, expired food inside R1’s personal refrigerator, chemicals and sharp objects. 3 out of 3 staff interviewed denied removing any clothing items from R1’s bedroom to include R1’s shoes and jackets.

5 residents were interviewed. Based on interview, 5 out of 5 residents could not prove that staff removed items from their bedroom without any good reason.

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SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Kabariti
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2025

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20250422165928

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: 04/30/2025

NARRATIVE

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Based on interview with R1’s former roommate, R2 observed shoes outside their bedroom but was unsure how the shoes got there. R2 later found out it was R1’s shoes. R2 was unsure how the shoes got outside but states that R1 was upset and stated that staff put them there. R2 denied observing staff throw R1’s shoes outside and denied observing staff throw R1’s clothing items away.

When staff questioned R1 about the shoes that was observed over the fence, it was stated that R1 admitted to throwing his/her shoes over the fence and later apologized to staff.

Based on record review, R1 only safeguarded 1 shoe, 2 shirts, 2 shorts, 2 socks, 1 book, and 3 pairs of underwear. No additional items were safeguarded on the form to include a jacket and additional pairs of shoes.

R1’s records note that on 04/10/2025, staff observed expired and molded food inside R1’s personal refrigerator. Staff talked to R1 who started to get aggressive towards the staff for not letting staff clean and throw away items. 911 was called due to R1’s aggressive behavior towards the staff. There was no indication that R1's clothing items were removed to include shoes and a jacket.

The Department has investigated the above allegation. Based on interview, record review and observation the above allegation is unfounded meaning the allegation is false, could not have happened, and/or is without a reasonable basis. No deficiencies were cited per California Code of Regulations, Title 22.

This report was reviewed with Administrator, Samuel Apostol and Office Manager, Ivonne Chavez and a copy of the report was provided.

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SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Kabariti
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2025

LIC9099 (FAS) - (06/04)

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