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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435294143
Report Date: 04/26/2024
Date Signed: 05/02/2024 11:27:56 AM

Unsubstantiated


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
04/19/2024 and conducted by Evaluator Manuel Monter
COMPLAINT CONTROL NUMBER: 26-AS-20240419161735
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:
04/26/2024
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Administrator Samuel ApostolTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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9
Staff forced resident to sign documents
Staff did not allow resident to have a private visitation
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced visit to deliver findings regarding the allegation listed above. LPA met with facility Administrator (ADM) Samuel Apostol. This Report is beng amended and the findings are being changed from Unfounded to Unsubstantiated due to new information.
On April 19, 2024 the Department received a complaint alleging Staff did not allow resident to have a private visitation.
On April 26, 2024, LPA's interviewed residents R1-R10. 8 Out of 10 residents inteviewed (R2-R3, R5-R10) stated the facility provides them with privacy, when having visitors. R1 & R4 stated they did not know if they had privacy.
On April 26 & May 2,2024 LPA interview facility ADM. ADM stated the staff are instructed to give the residents and their case managers space if they are requesting privacy. ADM stated if the case manager asks staff member for privacy, then staff will give the resident and their case manager privacy. ADM confirmed if residents are talking in the gazebo area with their Case manager, then staff will give them privacy.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2024
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 2
Control Number 26-AS-20240419161735
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: 04/26/2024
NARRATIVE
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On May 2, 2024, LPA interviewed 6 staff, (S1-S6). All staff interviewed stated they give residents privacy when they are meeting with their case managers. S1 & S2 stated the front yard gazebo is sometimes used by staff to eat their lunch, but if a case manager is already there, the staff will give them privacy. S6 stated he/she and S4 were already eating lunch when R1 arrived with his/her case manager.
Staff Forced Resident to Sign Documents
On April 19, 2024 the department received a complaint alleging Staff forced resident to sign documents

On April 26, 2024, LPA's interviewed residents R1-R10. 8 Out of 10 (R2-R3, R5-R10) residents interviewed stated the facility did not force them to sign documents. R4 stated he/she did not know if he/she was forced to sign documents. R1 stated he/she was forced to sign documents, but doesn't know what he/she was forced to sign or when he/she was forced to sign the documents.

On April 26 & May 2, 2024, 2024, LPA interviewed facility ADM. ADM stated the facility does not force residents to sign documents. ADM stated if a resident does not want to sign, then they will write, "refused to sign." ADM stated he will then inform their case manager that the resident is refusing to sign. ADM confirmed that R1's social worker was present when R1 was admitted. ADM stated R1's social worker was explaining to R1 what was being signed.

On May 2, 2024, LPA interviewed R1. LPA showed R1 his/her resident file. LPA showed R1 the signed documents and R1 confirmed those were the documents he/she signed, this included R1's Identification and emergency information form, Personal Rights, Admission Agreement, Photo release, House rules, Personal Property form, Consent for Emergency Medical Treatment & Release of Client medical information form. R1 stated he/she does not like to sign forms because he/she stated once she signs, she's responsible. R1 confirmed that he/she was not forced or coerced but the staff. R1 stated she likes living at the facility and likes her roommate, R1 confirmed his/her social worker was with him/her when he/she signed.

Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur. No deficiencies cited, an exit interview conducted with Administrator, Sam Apostol and a copy of the report was provided. END OF REPORT.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2024
LIC9099 (FAS) - (06/04)
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