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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294143
Report Date: 10/10/2023
Date Signed: 10/10/2023 04:51:37 PM


Document Has Been Signed on 10/10/2023 04:51 PM - 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: 44DATE:
10/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator Sam ApostolTIME COMPLETED:
04:00 PM
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Licensing Program Analysts (LPA) Manuel Monter and Mita Partoza conducted an unannounced annual inspection visit, and met with Administrator(ADM) Sam Apostol.

LPA toured the facility inside out with ADM which included; the Living room, kitchen, dinning room, facility restrooms and 10 residents bedrooms. During LPA's tour of the resident bedrooms, LPA's observed residents bed sheet were observed to be recently changed. The medication room of the facility was also inspected. Front yard and backyard were inspected. LPA observed fly traps were observed and ADM stated the facility changes the fly traps once a week. There was no obstruction to block the walkways. LPA observed the front yard free of debris and in good condition.

Two day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 75 degree F, and hot water temperature was measured in 3 facility bathrooms. The water temperature ranges from 105 to 110 degrees F.

Fire extinguisher was serviced in March 2023. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. The fire alarm system was last inspected on 07/06/2023. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on October 2023.

LPA reviewed facility records for 3 staff and 4 residents. LPA reviewed 3 resident medications and centrally stored medication records. LPA conducted interviews with 4 staff (S1 to S4) and 4 residents (R1-R4).

No deficiencies cited during today's visit. This report was reviewed with ADM Sam Apostol and a copy of the signed report was provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2023
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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