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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435294143
Report Date: 10/19/2023
Date Signed: 10/19/2023 04:48:35 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
08/25/2022 and conducted by Evaluator Manuel Monter
COMPLAINT CONTROL NUMBER: 26-AS-20220825122345
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:
10/19/2023
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Administrator Samuel ApostolTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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Resident had to be hospitalized while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced visit to deliver findings regarding the allegation listed above. LPAs met with facility Administrator (ADM) Samuel Apostol.

On 08/25/2022 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 a 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 ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (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)
Page: 1 of 5
Control Number 26-AS-20220825122345
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 witnessed fall.
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SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (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)
Page: 2 of 5
Control Number 26-AS-20220825122345
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.

Deficiencies are being cited. See LIC 9099-D. Exit interview conducted with Administrator Samuel Apostol and a signed copy of this report was provided along with appeal rights.

An immediate civil penalty of $500.00 is being assessed against the facility today for violation resulting in serious injury to a resident in care. An additional Civil Penalty in the amount of $9,500.00 for violation resulting in serious bodily injury is pending review.

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SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (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)
Page: 3 of 5
Control Number 26-AS-20220825122345
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: 10/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/20/2023
Section Cited
CCR
87468.2(a)(4)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a)(4) To care, supervision, and services that meet their individual needs and are delivered by staff ... to meet their needs.
This requirement was not met as evidenced by
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Licensee stated he will send plan of action on how the facility will meet the residents needs after a resident has fallen. Licensee stated he will send POC by 10/20/2023 to LPA.
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Based on investigation, R1 did not receive immediate medical assistance after R1 fell and subsequently verbalized having pain. Staff did not adhere to facility’s protocol on medical emergency by calling 9-1-1
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Type A
10/20/2023
Section Cited
CCR
87405(d)(1)
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87405 Administrator - Qualifications and Duties (d)(1) Knowledge of the requirements for providing care and supervision appropriate to the residents. This requirement was not met as evidenced by:
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Licensee stated he will send letter of understanding regaring the regulation and his role and responbilities as ADM and how he will provide care and supervison to the residents. Licensee stated he will send POC by 10/20/2023 to LPA.
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Based on investigation, ADM was not aware of R1’s fall because according to ADM he/she does not read staff notes on the weekend. ADM also did not inform R1’s CM of R1’s fall and R1 being a fall risk was not addressed in 2019 when he/she had his/her initial fall at the facility.
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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 ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 26-AS-20220825122345
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: 10/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/26/2023
Section Cited
CCR
87463(a)
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87463 Reappraisals (a) The pre admission appraisal shall be updated, in writing as frequently as necessary to note significant changes ...document changes in the resident's physical, medical, mental, and social condition. This requirement was not met as evidenced by:
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Licensee stated he will send Plan of action on how the facilty will updates residents needs and services plans when residents have changes in conditioin. Licensee stated he will send POC by 10/26/2023 to LPA.
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Based on investigation, R1 was a fall risk with an associated fall history. R1 had a fall in 2019. A review of R1’s LIC624 Appraisal Needs and Services Plan (ANS) dated Feburary 2, 2019, the facility did not update R1’s ANS to address fall prevention.
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Type B
10/26/2023
Section Cited
CCR
87468.1(a)(8)
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87468.1 Personal Rights of Residents in All Facilities (a)(8) To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. This requirement was not met as evicenced by;
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Licensee stated he will send plan of action on how the facilty will regulary inform residents representatives about their care, ongoing evaluations. Licensee stated he will send by POC date, 10/26/2023 to LPA.
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Based on investigation, R1’s responsible party and/or Case Manager was not immediately informed when R1 had a fall and current health condition before he/she was admitted to the hospital.
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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 ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023
LIC9099 (FAS) - (06/04)
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