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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294143
Report Date: 12/18/2024
Date Signed: 12/18/2024 11:50:44 AM

Document Has Been Signed on 12/18/2024 11:50 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/
DIRECTOR:
APOSTOL, SAMUEL C.FACILITY TYPE:
740
ADDRESS:460 CHURCH AVENUETELEPHONE:
(408) 683-0229
CITY:SAN MARTINSTATE: CAZIP CODE:
95046
CAPACITY: 46TOTAL ENROLLED CHILDREN: 0CENSUS: 43DATE:
12/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Administrator Samuel ApostolTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator (ADM) Samuel Apostol. During the visit, ADM stated the home has 43 residents LPA explained the purpose of the visit.

LPA toured the facility inside out with S1 which included the Living room, kitchen, dining room, restrooms and residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected. There was no obstruction to block the walkways.

Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 70 degrees F, and hot water temperature was measured to range from 112-116 degrees F in resident bathrooms.

Fire extinguisher was serviced in April 29, 2024. The facility was equipped with smoke and carbon monoxide detectors. The fire alarm system was last inspected in October 2024. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on December 1, 2024. LPA conducted interviews with 2 staff and 3 residents.

LPA reviewed facility records for 4 staff and 5 residents. LPA reviewed 5 resident medications and centrally stored medication records (CMR). 5 Out of 5 CMR's reviewed did not have the start date written on the log for all residents reviewed. While reviewing R2's CMR, LPA observed 2 medications were not listed on the centrally stored medication log.

A Deficiency is being cited & a technical assistance was provided during today's visit. This report was reviewed with ADM Samuel Apostol and a copy of the signed report and Appeal; rights were provided.
Romeo ManzanoTELEPHONE: (408) 388-2297
Manuel MonterTELEPHONE: (408) 324-2112
DATE: 12/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/18/2024 11:50 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 12/18/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
87465 Incidental Medical and Dental Care (h) (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Based on a review of R1-R5's centrally stored medication record, R1-R5's medication start dates is not listed for all 5 residents. While reviewing R2's medications, LPA observed Medication M1 & M2 were not listed on R2's Centrally Stored Medication record. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/25/2024
Plan of Correction
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ADM stated he will send LPA a copy of the updated centrally stored log's for R1-R5 showing the start dates. ADM stated he will send LPA a copy of R2's centrally stored log showing Medication M1 & M2 on the Centrally stored medication record. ADM stated he will also send a letter of understanding regarding the regulation, & the importance of ensuring a complete and accurate centrally stored medication record. ADM stated he will send the plan of correction by 12/25/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Romeo ManzanoTELEPHONE: (408) 388-2297
Manuel MonterTELEPHONE: (408) 324-2112

DATE: 12/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/18/2024

LIC809 (FAS) - (06/04)
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