435294143-7-9-2025-26-AS-KHOS-DJLH4B-20250715055140

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435294143
Report Date: 07/09/2025
Date Signed: 07/09/2025 11:51:47 AM

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
04/04/2025 and conducted by Evaluator Christine Kabariti

COMPLAINT CONTROL NUMBER: 26-AS-20250404111503

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: 41	DATE:	07/09/2025
		UNANNOUNCED	TIME BEGAN:	11:20 AM
MET WITH:	Samuel Apostol		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Facility staff not meeting resident's incontinence care needs

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to deliver the finding for the above allegation. LPA met with Administrator(ADM) Samuel Apostol and Office Manager (OM) Ivonne Chavez.

On 04/04/2025, the Department receive a complaint regarding the above allegation. On 04/11/2025, the initial complaint investigation was conducted. The following documents were obtained to include the resident roster, resident tracking log, list of fall risk/incontinent residents, 3 resident's physician's report, appraisal/needs and services plan, admission agreement and progress notes.

It was alleged that the facility staff are not meeting resident (R1’s) incontinent care needs as the resident was often observed wearing a diaper full of urine resulting in R1’s bedroom smelling of urine. Page 1 of 3.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Kabariti
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2025

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-20250404111503

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: 07/09/2025

NARRATIVE

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R1 was admitted to the facility on 03/03/2025.

3 residents were interviewed. Based on interview, 1 out of 3 resident stated to have helped R1 clean his/her bed with a witness (W1) because R1 and R1’s bed was soiled. This resident stated to have voluntarily cleaned R1’s bed because the staff was taking too long to come to the room. This resident denied staff checking on the residents regularly and in the morning. 2 out of 3 residents interviewed stated that the staff check in on the residents daily in the morning and throughout the day, and denied observing other residents left in soiled adult briefs.

Based on interview with witness (W1), W1 observed R1 laying in bed soaked full of urine about 3 times since he/she has visited the facility. W1 was unable to recall the dates of observation. W1 stated that he/she visits the facility daily at 10:00am and around 2:00pm. It was stated that he/she has observed R1 left laying in his/her urine around 10:00am and when he/she returned to the facility at 2:00pm.

W1 states that when he/she observed R1 laying in bed soaked in urine, W1 did not tell the staff. W1 states that there was always staff in the hallways and assumed they’d check in on R1. W1 denied observing staff help R1.

The review of R1’s pre-placement appraisal notes that R1 is incontinent and did not need help with toileting but needs help with bathing and personal hygiene.

6 staff members were interviewed. Based on staff interview, it was stated that R1 came from an independent living home. The facility was informed that R1 was able to change his/her own adult briefs. It was stated that when R1 first moved in, R1 refused staff assistance to change his/her adult brief and any assistance in the bathroom. Staff stated that in beginning R1 needed to be constantly reminded to use the bathroom and change his/her adult briefs. Staff members stated that they ensure R1 is checked and asked every 2 hours to go to the bathroom and to change his/her adult brief.

Page 2 of 3.

SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Kabariti
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20250404111503

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: 07/09/2025

NARRATIVE

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The review of facility records shows that the facility noted on 03/12/2025 that R1 woke up with a wet bed and heavy adult brief but did not want to change his/her adult brief. Staff asked R1 to return to his/her room and change his/her adult brief. On 03/16/2025, a staff communication was noted to make sure R1 changed his/her adult brief every 2 hours and to shower if necessary.

Based on observation on 04/11/2025, R1 was not observed soiled around 10:00am and 11:00am. R1’s bedroom did not have an odor of urine and feces.

The Department has investigated the above allegation. Based on interview, record review and observation the above allegation is unsubstantiated. An unsubstantiated finding indicates that although the allegation may have happened and/or is valid there is not a preponderance of evidence to prove the alleged violation did or did not occur.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator(ADM) Samuel Apostol and Office Manager (OM) Ivonne Chavez and a copy of the report was provided.

Page 3 of 3.

SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Kabariti
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2025

LIC9099 (FAS) - (06/04)

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