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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294143
Report Date: 07/23/2024
Date Signed: 07/23/2024 10:29:35 AM


Document Has Been Signed on 07/23/2024 10:29 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: 38DATE:
07/23/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator Samuel ApostolTIME COMPLETED:
10:35 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
Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced Case Management to conduct a Non-Compliance Plan Visit. LPA met with Administrator(ADM) Samuel Apostol and stated the purpose of today's visit.

The purpose of the visit is to ensure the facility is adhering to the Compliance Plan submitted to Community Care Licensing (CCL) after an informal meeting held on 02/08/2024.

During visit, LPA toured the facility with ADM, inside and out. All fire exit routes were free and clear of obstruction. LPA observed signs for the residents who are a fall risk. LPA observed fly traps in the backyard smoking area. During the tour, LPA observed facility protocol for contacting 911 and what to do if a resident has a fall throughout the facility.

LPA reviewed 2 resident files, which included but not limited to; physicians report, needs and services plan, and admission agreement. LPA also reviewed staff training files and facility file. LPA observed facility maintenance log and the 2 hourly check log. LPA observed the fall risk log, which contains the list of resident who are a fall risk.

No deficiencies cited per California Code of Regulations, Title 22. This report was reviewed with Administrator Samuel Apostol and a copy of the report was provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024
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