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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294143
Report Date: 05/02/2024
Date Signed: 05/02/2024 11:17:49 AM


Document Has Been Signed on 05/02/2024 11:17 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: 39DATE:
05/02/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Administrator Samuel ApostolTIME COMPLETED:
11:20 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
Licensing Program Analyst (LPA) Manuel Monter arrived unannounced to conduct a case management to amend a complaint investigation LIC9099 and LIC9099-C issued on April 26, 2024 (26-AS-20240419161735) due to additional information.

LPA met with Administrator Samuel Apostol.

No deficiencies cited. A copy of the report was provided to Administrator Samuel Apostol.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2024
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