<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294143
Report Date: 02/21/2024
Date Signed: 02/21/2024 11:35:36 AM


Document Has Been Signed on 02/21/2024 11:35 AM - 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: 45DATE:
02/21/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator Samuel ApostolTIME COMPLETED:
11:35 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On February 21, 2024, Licensing Program Analyst, Manuel Monter conducted an unannounced case management visit. The purpose of this case management is regarding an incident that occurred on July 2, 2023, where R1 grabbed a fork and stabbed R2 on the forehead.

On July 28, 2023, the Department received an incident report regarding resident R1 assaulting resident R2 around 12pm. R2 was taken to the hospital and has returned to the facility. As a result, R1 was arrested.

On August 01, 2023, the Department conducted a preliminary case management visit to get residents R1 and R2’s documents. LPA also requested facility staff schedule and progress notes.

On August 28,2023 the Department interviewed resident R2, Staff S1-S3, and Administrator (ADM) regarding the altercation that occurred on July 2, 2023.

Based on the Department’s investigation, while staff S1 was about to serve food to the residents, S1 noticed that resident R1 and R2 were arguing at the dining area during a mealtime. S1 saw that R1 got a fork and stabbed R2 on the forehead. S1 stated that ADM was close by and grabbed R1 by the hand that was holding the fork to prevent the assault from continuing. S1 was also grabbing R1’s other hand at the same time. S1 stated staff S2 and S3 assisted as well once they heard the commotion.

R2 confirmed that either S1 or S3 were present in the area and staff members pulled R1 off of him/her.

The Department has completed the investigation of the above allegations. Based on interviews conducted and record reviews, the Department has found that the allegation of neglect/lack of supervision were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. No deficiencies cited during today’s visit. A copy of the report was provided to ADM.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1