435294143-10-7-2025-26-AS-RMAO-DMEK3D-20251013073234

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435294143
Report Date: 10/07/2025
Date Signed: 10/07/2025 03:58:16 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
09/30/2025 and conducted by Evaluator Christine Kabariti

COMPLAINT CONTROL NUMBER: 26-AS-20250930133622

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: 43	DATE:	10/07/2025
		UNANNOUNCED	TIME BEGAN:	01:50 PM
MET WITH:	Administrator, Sam Apostol		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Facility staff did not take appropriate measures to safeguard resident’s belongings resulting in resident missing multiple items
Facility staff does not accord resident with privacy during showers

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to deliver the finding for the above allegations. LPA met with Administrator, Sam Apostol and Office Manager, Ivonne Chavez.

On 09/30/2025, the Department received the complaint alleging the above allegations. On 10/03/2025, the initial complaint investigation was conducted. Documents were obtained to include resident roster, physician's report and appraisal needs and services plan & pre-appraisal assessment.

It was alleged that the facility staff did not take appropriate measures to safeguard resident (R1)’s clothing items, leg brace that was prescribed by the doctor, cell phone, and a cell phone charger. It was also alleged that the R1's clothing items were locked inside the washing machine and the staff are unable to take them out. Page 1 of 3.

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Kabariti
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025

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-20250930133622

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: 10/07/2025

NARRATIVE

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Resident (R1) was interviewed who stated that he/she only came to the facility with a suitcase, clothes, and a cane. R1 states he/she did not come to the facility with any other item to include a leg brace. R1 states that he/she only came with a few clothes but his/her family member and facility staff bought extra clothes for him/her. R1 states that he/she has 2 cell phones and a phone charger. R1 stated that his/her family member bought clothes for him/her but all the clothes are locked in the washing machine.

2 staff members were interview. Based on staff interviews, R1 did not come to the facility with a leg brace. It was stated that R1's previous facility did not send all his/her personal items and R1 only came with the clothes he/she was wearing, a guitar and a cane.

Based on observation of R1's bedroom, LPA Kabariti observed R1's closet has at least 5 pairs of pants, at least 6 shirts, socks and briefs. LPA Kabariti observed additional clothing items on the floor next to R1's bed, 2 cell phones, a charger which R1 states he/she uses for his/her cell phone, and a walker.

The review of records shows that R1 was admitted to the facility in July 2024. When R1 moved into the facility items that were safeguarded included a cell phone and clothing items but the leg brace and cell phone charger was not listed as part of safeguard items.

LPA Kabariti entered into the laundry room with staff and observed the washer and dryers were in good repair. LPA observed the washers and dryers were in use. It was stated that all resident clothing items are labeled with the resident's name, which LPA observed. The office manager and Administrator states that the resident's clothing items are washed daily and as needed. LPA observed the laundry room is locked and only accessible to staff.

It was also alleged that the facility staff does not accord resident with privacy during showers. Based on the reporting party (RP), it was stated that R1 has a health condition where he/she has difficulty walking and cannot stand for a long period of time. It was stated that R1 did not like that staff were sitting in the shower with him/her.
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SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Kabariti
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20250930133622

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: 10/07/2025

NARRATIVE

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Based on interview with R1, it was stated that he/she has to ask permission to use the shower because the shower rooms are locked. R1 stated that before, there used to be a staff who sat in the shower room while R1 was showering and R1 did not like that. R1 states that now, the staff waits outside for him/her to finishing showering. R1 states they wait outside for him/her in case R1 has a fall.

Based on record review, R1 does have the capacity for self-care to include bathing, dressing and grooming, but has a condition that affects his/her movement and coordination.

2 staff members interviewed stated that because they are an assisted living facility the staff supervise the residents during shower for their safety, such as a fall.

It was stated that the staff assist R1 in the shower because they are afraid that R1 will fall due to his/her health condition.

S1 and S2 stated that if a resident does not feel comfortable with the staff assisting them in the shower and they are able, the staff would do a body check of the resident to ensure there are no changes in condition, and then step outside and wait for the resident to finish showering.

The Department has investigated the above allegations. Based on interview, record review and observation the above allegations are unfounded, meaning the allegations are false, could not have happened, and/or is without reasonable basis.

No deficiencies were cited per California Code of Regulations, Title 22.

This report was reviewed with Administrator, Sam 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: 10/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025

LIC9099 (FAS) - (06/04)

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