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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294143
Report Date: 02/08/2024
Date Signed: 02/08/2024 02:56:17 PM


Document Has Been Signed on 02/08/2024 02:56 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: DATE:
02/08/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Samuel C ApostolTIME COMPLETED:
03:00 PM
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A Noncompliance meeting was conducted on February 8, 2024 at CCLD San Jose office. Present at the meeting were San Bruno Adult and Senior Care Regional Manager Vivien Helbling, Licensing Program Manager Romeo Manzano, Licensing Program Analysts Simi Rai and Manuel Monter, Licensee/Administrator Samuel C Apostol.

The purpose of the noncompliance meeting was to discussed a substantiated complaint allegations for the following date: 08/25/2022, 2/10/2022, 03/15/2018. As a result, the allegation is Substantiated. Deficiencies were cited for violations of Title 22 California Code of Regulations.

Noncompliance Conference Summary LIC 9111 and compliance plans were established during the meeting. The facility will begin a 2 year monitoring plan by licensing which includes more frequent licensing inspections.

Additional civil penalties are being reviewed.

Report was reviewed with facility Licensee. A copy of this report, LIC 9111 was provided to licensee during today's office visit.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2024
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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