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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435294143
Report Date: 06/07/2024
Date Signed: 06/07/2024 09:59:04 AM

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
05/09/2024 and conducted by Evaluator Manuel Monter
COMPLAINT CONTROL NUMBER: 26-AS-20240509125227
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: 38DATE:
06/07/2024
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Administrator Samuel ApostolTIME COMPLETED:
10:10 AM
ALLEGATION(S):
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Facility staff did not prevent physical altercation between residents
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.

On May 9, 2024, the Department received a complaint alleging Facility staff did not prevent physical altercation between residents. It has been alleged that resident R2 pushed R1.

On May 16, 2024, LPA Monter interviewed residents R1-R13. 1 Out of 13 residents interviewed (R1) stated R2 had pushed R1. 4 Out of 13 residents interviewed (R2, R4, R5, R12) stated R2 did not push R1 and R1 had bumped into R2, causing R1 to fall. 8 Out of 13 residents (R3, R6-R11, R13) stated they did not see the alleged altercation between R2 and R1.

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Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024
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 3
Control Number 26-AS-20240509125227
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: 06/07/2024
NARRATIVE
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Resident R1 stated R2 came running and hit R1. R1 stated R2 had pushed him/her and hit him/her on the head, shoulder, and spine.

Resident R2 stated he/she started walking towards the home to go inside. R2 stated R1 then got in front of R1 and they bumped into each other. R2 stated when R1 bumped into R2, R1 fell down. R2 denies pushing R1.

On May 16, 2024 and June 5, 2024, LPA interviewed 3 staff (S1-S3) and facility ADM. 3 Out of 3 staff and facility ADM stated they did not witness the R2 pushing R1. ADM stated the alleged altercation occurred during dinner time, while he was in his office. Staff S1 stated he/she was in the medication room prepare medications for the 5pm pass out. Staff S2 stated he/she was in the kitchen preparing the food for the second seating and was keeping an eye on dinning residents. S3 stated he/she was in the laundry room. All staff interviewed stated they did not hear residents R1 or R2 yelling, arguing or screaming prior to the alleged incident.

ADM stated he was informed by R1 that he/she was pushed by R2. ADM stated he assessed the resident and called 911, following his fall protocol. ADM stated R1 had returned from the hospital the same day with no new orders.

Based on record review, there is no history of physical altercations between resident R1 and R2.

Although R1 falling is a fact, based on interviews conducted, this incident was caused by R1 and R2 bumping into each other, was an accident. As this incident happened in a split moment, with no prior audio ques, facility staff could not feasibly prevent resident R2 from accidentally bumping into R1. Facility staff also responded immediately once they became aware of the alleged incident and sought timely medical attention for R1, per facility policies.

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SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 26-AS-20240509125227
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: 06/07/2024
NARRATIVE
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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.

END OF REPORT.

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SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3