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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435294143
Report Date: 07/09/2025
Date Signed: 07/09/2025 11:52:57 AM

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
04/25/2025 and conducted by Evaluator Christine Kabariti
COMPLAINT CONTROL NUMBER: 26-AS-20250425092020
FACILITY NAME:SOUTH COUNTY RETIREMENT HOME INC.FACILITY NUMBER:
435294143
ADMINISTRATOR:APOSTOL, SAMUEL C.FACILITY TYPE:
740
ADDRESS:460 CHURCH AVENUETELEPHONE:
(408) 683-0229
CITY:SAN MARTINSTATE: CAZIP CODE:
95046
CAPACITY:46CENSUS: 41DATE:
07/09/2025
UNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Samuel ApostolTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility Administrator did not address resident’s sleep concerns affecting his/her health.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to deliver the complaint investigation finding. LPA met with Administrator(ADM) Samuel Apostol and Office Manager (OM) Ivonne Chavez.

On 04/25/2025, the Department received the complaint. On 04/30/2025, the initial complaint investigation was conducted. The following documents were obtained to include 2 residents physician's report, appraisal/needs and services plan, identification and emergency contact information, progress notes, and admission agreement. It was alleged that the facility Administrator did not address resident (R1)’s sleep concerns as R1’s roommate (R2) snores at night, which is causing sleep deprivation and affecting R1’s health.

2 staff members and Administrator were interviewed. Based on interview with the Administrator, it was stated that the facility has changed out R1’s roommate about 3 times due to different conflicts R1 had with his/her roommates. Page 1 of 2.
Unfounded
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 2
Control Number 26-AS-20250425092020
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 Administrator stated that R1 does not like to have a roommate, however, is unable to pay for the cost of a private bedroom. Administrator stated that R1 was aware that his/her bedroom would be a shared bedroom and consented to it.

It was stated that due to conflicts with R1’s previous roommate, they thought R2 would be a good fit to be R1’s roommate

Administrator stated to address R1’s sleep concerns they have provided R1 was ear plugs and reached out to R1’s case manager. It was stated that R1 also had headphone that he/she uses during the night. It was stated that due to the constant roommate switches, the facility has challenges in finding another roommate who would be compatible with R1’s needs. It was stated that it was also unfair to move residents around who are already settled and comfortable in their rooms. Administrator denied R1 reaching out to request for a specific roommate.

Based on interview with R1, it was stated that R1 had a preference for which roommate he/she preferred. R1 stated that he/she did not talk to the Administrator and staff regarding his/her roommate request. R1 stated that he/she found ear plugs inside his/her room on 04/30/2025 but R1 didn’t need that as R1 was already using noise canceling headphones. R1 states that even with the use of noise canceling headphone, R2’s snoring was too loud that he/she can hear it through the headphones resulting in sleep deprivation. R1 did not want to inform the Administrator of his/her request and consented for LPA Kabariti to inform the Administrator regarding his/her roommate request.

On 05/01/2025, the Administrator switched R1’s roommate to the preferred roommate R1 requested. Based on record review, it was stated that R1 and R3 both agreed to share a room.

The Department has investigated the above allegation. Based on interview and record review, 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(ADM) Samuel Apostol and Office Manager (OM) Ivonne Chavez and a copy of the report was provided.
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 2