435294143-11-15-2024-26-AS-KHOS-DBCQKG-20241125111421

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435294143
Report Date: 11/15/2024
Date Signed: 11/15/2024 01:10:55 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
08/26/2024 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20240826154515

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: 45	DATE:	11/15/2024
		UNANNOUNCED	TIME BEGAN:	12:10 PM
MET WITH:	Administrator Samuel Apostol		TIME COMPLETED:	01:20 PM

ALLEGATION(S):

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Facility staff withholding prescribed medication causing resident to be hospitalized
Facility staff selling resident's medication for financial gain

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Monter conducted an unannounced complaint investigation to deliver the findings on the above allegations. LPA met with Administrator Samuel Apostol.

On August 26, 2024, the Department received a complaint alleging Facility staff withholding prescribed medication causing resident to be hospitalized. It has been alleged that that facility staff withheld R1’s medication.

On September 5, 2024, Licensing Program Analyst Manuel Monter interviewed 5 residents. (R2-R6). 5 Out of 5 Residents interviewed stated they get their medication everyday & staff does not withhold residents’ medications.

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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: 11/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

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 4

Control Number 26-AS-20240826154515

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: 11/15/2024

NARRATIVE

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LPA Monter interviewed Staff S1-S5. 5 Out of 5 staff interviewed stated staff do not withhold residents’ medications. 5 Out of 5 staff interviewed stated residents’ medications are being administered daily.

LPA interviewed ADM. ADM stated facility staff does not withhold residents’ medications. ADM stated residents’ medications are being administered.

On November 12, 2024, LPA Monter interviewed R1. R1 stated the facility did not administer his/her medication, such as his/her antibiotic medication, because he/she knew about staff S1’s Infidelity. R1 stated he/she does not know the name of the medications he/she wasn’t given. R1 stated he/she doesn’t remember when the medication was not administered either.

On November 15, 2024, LPA Monter interviewed residents R7-R12. 5 Out of 6 residents interviewed (R7-R11) stated they get their medication daily and staff does not withhold their medications. 1 Out of 6 residents interviewed (R12), stated he/she does not want to answer LPA's questions and declined to be interviewed.

Based on a review of R1’s Physicians Report, dated September 22, 2014, and Needs and services plan, dated February 5, 2023, states R1 experiences auditory and visual hallucinations. The Physicians Report also states R1 is paranoid that something is trying to get him/her.

Based on a review of R1’s Medication Administration Log, the form shows R1’s medications were administered. Further review of R1’s medication administration record showed R1’s antibiotics were administered as well.

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.

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SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 26-AS-20240826154515

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: 11/15/2024

NARRATIVE

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Facility staff selling resident's medication for financial gain

On August 26, 2024, the Department received a complaint alleging staff selling resident's medication for financial gain. It has been alleged that R1’s medications were sold for financial gain.

On September 5, 2024, Licensing Program Analyst Manuel Monter interviewed Staff S1-S5. 5 Out of 5 staff interviewed stated staff do not sell residents medications.

LPA Monter interviewed residents R2-R6. 5 Out of 5 Residents interviewed stated they get their medication everyday and staff do not withhold their medication.

On November 12, 2024, LPA Monter interviewed R1. R1 stated the facility did not administer his/her medication, such as his/her antibiotic medication, because he/she knew about staff S1’s Infidelity. R1 stated he/she does not know the name of the medications he/she wasn’t given. R1 stated he/she doesn’t remember when the medication was not administered either. R1 stated he/she overheard S1 talking to a family member on the phone discussing selling R1’s medications. R1 stated he/she does not remember when this phone call took place.

On November 15, 2024, LPA Monter interviewed residents R7-R12. 5 Out of 6 residents interviewed (R7-R11) stated they get their medication daily and staff does not withhold their medications. 1 Out of 6 residents interviewed (R12), stated he/she does not want to answer LPA's questions and declined to be interviewed.

Based on a review of R1’s Physicians Report, dated September 22, 2014, and Needs and services plan, dated February 5, 2023, states R1 experiences auditory and visual hallucinations. The Physicians Report also states R1 is paranoid that something is trying to get him/her.

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SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 4

Control Number 26-AS-20240826154515

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: 11/15/2024

NARRATIVE

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Based on a review of R1’s Medication Administration Log, the form states R1’s medications were administered. Further review of R1’s medication administration record showed R1’s antibiotics were administered as well.

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.

Page 4 Out of 4. END OF REPORT.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4