435294143-10-19-2023-26-AS-RMAO-CX63VY-20231031183556

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435294143
Report Date: 10/19/2023
Date Signed: 10/19/2023 04:43:51 PM

Substantiated

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 Manuel Monter

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: 44	DATE:	10/19/2023
		UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Administrator Samuel Apostol		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Resident fell and sustained an injury
Staff did not seek timely medical attention for resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPAs) Manuel Monter conducted an unannounced visit to deliver findings regarding the allegation listed above. LPA met with facility Administrator (ADM) Samuel Apostol.

On October 24, 2022 the department received a complaint alleging that a resident fell and sustained an injury. It has also been alleged that staff did not seek timely medical attention for resident.

The investigation revealed either 08/20/2022 or 08/21/2022 during the night shift, a resident living at the facility (R1) was searching for cigarette buds in the facility’s backyard and had an unwitnessed fall around 0600 hours. A staff member (S1) brought R1 inside of the facility and placed him/her in a wheelchair. S1 assessed R1 for pain wherein R1 stated he/she was fine. S1 stated R1 was able to lift his/her left leg while the right leg hurts. S1 informed staff S2 that R1 fell outside.

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Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023

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

LIC9099 (FAS) - (06/04)

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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: 10/19/2023

NARRATIVE

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The Department obtained a copy of the facility staff ‘pass-down notes.’ Based on review that on August 21, 2022, or August 22, 2022, at around 6am, a resident R2 informed staff S1 that R1 had fallen. S1 went to check and found R1 on the ground. S1 observed a bowel movement next to R1. S1 asked R1 “did you have an accident out here?” R1 responded, “no, I don’t know.” S1 asked R1 if he/she was in pain, R1 responded that he/she was okay. S1 told R1 to get up after cleaning him/her and R1 requested help. S1 stated R1 has fallen before and rarely asks for help. R1 requested help from S1. When R1 got up and tried to walk R1 said he/she felt pain on his/her upper right leg.

On August 22, 2022, S1 asked R1 if he/she was in pain. R1 told S1 that he/she “still had pain.”

On August 23, 2022, R1 told staff (S3) that he/she was in a lot of pain and that he/she “hurt so bad”. S3 contacted 911 services.

On February 28, 2023, ADM was interviewed. ADM stated he/she reads the staffs notebook of "pass down notes" "mostly every day." ADM stated that on August 21, 2022, was a Sunday and ADM does not read the staff's notebook on the weekends. ADM stated, "no one reported anything to her/him on Sunday." ADM explained the staff are all "trained to call 911 and he/she does not know why the staff did not call 911 this time."

On November 18, 2022, R1’s Case Manager (CM) was interviewed. CM stated, “the facility called him/her after R1 had been transported to the hospital…R1 was complaining of pain… had been in a wheelchair for two days”. CM stated he/she did not know that R1 fell at the facility two days before being taken to the hospital. A review of facility documentation did not show any documented evidence that the facility informed R1’s case manager about the fall incident before R1’s hospitalization on August 23, 2022.

A review of medical records indicated that R1 was transported and admitted to the hospital on August 23, 2022. While at the hospital, R1 was diagnosed with a right hip fracture.

On August 28, 2023, R1 passed away in the hospital due to complications with the surgery required to treat his/her hip fracture. R1's cause of death was due to heart failure complicated by a right hip fracture from an unwitnessed fall.
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SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023

LIC9099 (FAS) - (06/04)

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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: 10/19/2023

NARRATIVE

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A review of R1’s medical discharge records from the hospital from August 23 to 28, 2022 stated the R1 was admitted due to an unwitnessed fall associated with a right leg pain. R1’s right leg shortens and externally rotated. R1’s findings were of right closed displaced intertrochanteric hip fracture. Furthermore, R1 was found to have an acute comminuted intertrochanteric fracture of the right proximal femur.

According to Clevelanclinic.org, “a closed intertrochanteric fracture of the hip, right [happens when the upper part of the thighbone breaks, usually from a fall or a car accident].”

On February 28, 2023 & March 1, 2023, the Department conducted interviews with facility staff (S1 to S4) and ADM. S1, S4 & ADM stated R1 had fall incidents while in the facility. S4 stated R1 was hospitalized for a broken hip in 2019. (Before the August 23, 2022, hospitalization).

During a review of R1’s Appraisal Needs and Services Plan (ANS) and interview with ADM, the facility did not develop and implemented interventions to mitigate R1’s safety. ADM did not update R1’s ANS before and after R1 sustained injury.

The Department has investigated the above allegation. Based on records reviewed, and interviews conducted, the preponderance of evidence standard has been met. Therefore, the Department found the above allegation to be SUBSTANTIATED.

Exit interview conducted with Administrator, Sam Apostol and a copy of the report was provided.

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SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023

LIC9099 (FAS) - (06/04)

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