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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294143
Report Date: 08/01/2023
Date Signed: 08/01/2023 11:33:10 AM


Document Has Been Signed on 08/01/2023 11:33 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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
ADMINISTRATOR:APOSTOL, SAMUEL C.FACILITY TYPE:
740
ADDRESS:460 CHURCH AVENUETELEPHONE:
(408) 683-0229
CITY:SAN MARTINSTATE: CAZIP CODE:
95046
CAPACITY:46CENSUS: DATE:
08/01/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator Samuel ApostolTIME COMPLETED:
11:35 AM
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LPA Manuel Monter conducted an unannounced case management visit in regards to an incident report the department received on 7/28/2023. LPA met with administrator (ADM) Samuel Apostol.

On 7/28/23 the department received an incident report regarding resident R1 assaulting resident R2 around 12pm. R2 was taken to the hospital and has returned to the facility. R1 was arrested by the sheriff. ADM stated he will not accept resident R1 back to the facility.

ADM was interviewed regarding his plan of action on keeping his residents safe and the facility's procedures for when residents begin to argue/fight with each other. ADM stated that the facility was actively watching resident R1 due to he/she no longer taking his/her medication. ADM stated on 7/24/23, resident R1 was beginning to refuse medication and claiming to staff that he/she fired the facility's staff as he/she is the owner. ADM stated he contacted the case manger, conservator and psychiatrist regarding resident R1 refusing to take his/her medication. ADM stated he informed his staff to keep an eye on R1 who was not taking his her medication.

ADM stated R1 and R2 are not roommates. ADM stated the facility will encourage resident who do not get along to avoid interacting with each other to avoid conflicts.

LPA asked for the following documents. The facility staff schedule, R1's progress notes, police report case number card. LPA also requested R1 and R2's updated appraisal needs and services plan. LPA advised ADM to put his plan of action on future incident reports.

LPA toured the facility. No deficiencies cited during todays visit. A copy of the report was provided to ADM
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 08/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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