435294143-6-22-2023-26-AS-RMAO-CX63VZ-20231031183556

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435294143
Report Date: 06/22/2023
Date Signed: 06/22/2023 04:55:19 PM

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
10/24/2022 and conducted by Evaluator Simranjit Rai

COMPLAINT CONTROL NUMBER: 26-AS-20221024102823

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: 46	DATE:	06/22/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Administrator, Sam Apostol		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Facility administrator falsifies training records
Staff did not notify resident's authorized representative of residents fall

INVESTIGATION FINDINGS:

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On 6/22/2023, LPAs Monter and Rai and LPM Manzano conducted an unannounced complaint investigation of the above allegation and met with Administrator, Sam Apostol.

On 10/24/2022, Community Care Licensing Division (CCLD) received a complaint with the above allegations.

On 10/24/2023, the initial investigation visit was conducted. The Department obtained staff training documents, a staff and resident roster, and staff schedule for the months of September and October of 2022.

Page 1 out of 2, see continuation on LIC 9099-C (Page 2).

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

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 6

Control Number 26-AS-20221024102823

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: 06/22/2023

NARRATIVE

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Facility administrator falsifies training records
The allegation stated the facility administrator falsifies the staff training records and puts the fake records in the staff files. During record review of staff files and training logs, LPA observed the training logs from 2013-2023. LPA observed either an RN, Administrator Sam Apostle or a third party vendor was providing facility staff training. The training logs which captured the staff signatures were made with different color ink and different signatures.

Staff did not notify resident's authorized representative of residents fall
The allegation stated the Resident (R1) had a fall on 8/13/22 and the staff also did not notify the resident's authorized representative that the resident fell. A staff member called the resident's authorized representative on or around 8/15 or 8/16/22 to let the authorized representative the resident was being sent to the hospital. During today's visit 6/22/2023, LPAs interviewed ADM and ADM stated the family was notified about the fall via phone call and does not have written record of the call.

The Department has investigated the above allegations. Based on LPA inspection, observations, records review, interviews with AD, staff, and residents, the preponderance of evidence standard has not been met therefore the allegations are UNSUBSTANTIATED. Meaning although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Administrator Samuel Apostol and a copy of the report was provided.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 6

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
10/24/2022 and conducted by Evaluator Simranjit Rai

COMPLAINT CONTROL NUMBER: 26-AS-20221024102823

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: 46	DATE:	06/22/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Administrator, Sam Apostol		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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9

Staff administer medication without medication training
Staff did not report incident involving resident to CCLD

INVESTIGATION FINDINGS:

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Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 26-AS-20221024102823

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: 06/22/2023

NARRATIVE

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Staff administer medication without medication training
The allegations stated a staff member (S1) without training is providing medications to the residents. Per interview with Administrator (ADM) Sam Apostol, facility staff did not have training due to the pandemic. LPAs reviewed the medication logs from September and October 2022 which includes the resident's medications, date and time the staff initials stating when and who gave the medications to the resident. ADM reviewed the initials on the medication record and they did not belong to S1.

Per staff interviews and resident interviews, S1 gives residents medications in the morning. LPAs interviewed S1, S1 stated S1 has given medications in the past couple of years when Med-Tech is on vacation or calls off sick. S1 stated did not receive medication training. Per S1, the medication is in little brown envelopes which are prepared in advance. Per record review, S1 has not received medication training in prior years, the only training record for S1 is for the year 2023.

Staff did not report incident involving resident to CCLD
The allegation stated the resident's fall which occurred on 8/13/2022 was not reported to CCLD by submitted an incident report. During today's visit, 6/22/2023, LPAs interviewed ADM and ADM could not produce the incident report for the resident's fall. ADM did report the hospitalization of the resident which occurred a couple of days later.

The Department has conducted an investigation of the above allegations. Based on interviews and records review, the preponderance of evidence standard has been met. Therefore, the Department found the above allegations to be SUBSTANTIATED. Deficiencies are being cited. See LIC 9099-D.

Exit interview conducted with Administrator, Sam Apostol. A copy of this report, along with the facility's appeal rights were provided.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 26-AS-20221024102823

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/22/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/29/2023 Section Cited HSC 1569.69	1 2 3 4 5 6 7	1569.69(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements. this requirment was not met at evidenced by;	1 2 3 4 5 6 7	ADM stated they will write written plan of action when designated medication staff is unavaliable to dispense medications.
	8 9 10 11 12 13 14	Based on Interview & record review. S1 admitted assiting with medication without medication training. Medication training records did not show S1 recive medication training in 2021 and 2022. ADM also confirmed this. This poses a potential health , safety and personal rights risk to residents.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

LIC9099 (FAS) - (06/04)

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