435294143-10-10-2023-26-AS-RMAO-CWHUL7-20231011154012

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435294143
Report Date: 10/10/2023
Date Signed: 10/10/2023 04:50:20 PM

Unfounded

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
10/02/2023 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20231002152059

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:	10/10/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Administrator Sam Apostol		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Mental/verbal abuse to resident.

INVESTIGATION FINDINGS:

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

On 10/02/2023 the department received a complaint alleging that a resident sustained mental/verbal abuse from staff and residents.

On 10/10/2023, LPA's interviewed R1. R1 stated the staff are not teasing, taunting, or saying mean things to him/her. R1 stated the female residents are teasing him/her regarding his/her girlfriend. R1 stated this is due to jealously. LPA asked R1 who was teasing him/her, R1 stated he/she did not know.

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Unfounded

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: 10/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

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-20231002152059

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: 10/10/2023

NARRATIVE

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LPA's interviewed 10 residents. 8 out of 10 residents denied the allegation that staff were teasing, taunting or saying mean things to residents. 7 out of 10 residents denied the allegation that residents were taunting, teasing, or saying mean things to other residents.

LPA's interviewed 3 staff members, S1-S3. 3 out of 3 staff members denied the allegation that staff were teasing, taunting or saying mean things to residents. 3 out of 3 staff members denied the allegation that residents were taunting, teasing or saying mean things to other residents.

LPA's interviewed ADM regarding the allegations. ADM stated the staff do not tease/taunt/say mean things to residents. ADM stated the residents will sometimes tease/taunt/ say mean things to one another. ADM stated the facility staff will intervene and de-escalate the situation. ADM stated the staff will try to re-direct the residents and encourage to cooperate as they live in the same home. ADM stated R1 accuses ADM of speaking with his/her wife. ADM stated R1 accuses others of talking with his/her wife.

A review of R1's Appraisal/Needs and Services Plan states; R1 struggles from paranoid thoughts and behaviors(past characterized by a generalized over concern of others). The form states R1 has delusional thoughts such as thinking his/her "girlfriend" is imprisoned. The form also states R1 is fixated on his/her "fiance" and paranoid of people talking to her or saying bad things.

The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.

No deficiencies cited, an exit interview conducted with Administrator, Sam Apostol and a copy of the report was provided.

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

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

LIC9099 (FAS) - (06/04)

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