435294143-5-27-2021-26-AS-KHOS-C3TKH4-20210609075432

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435294143
Report Date: 05/21/2021
Date Signed: 05/27/2021 01:29:10 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/08/2020 and conducted by Evaluator Marybeth Donovan

COMPLAINT CONTROL NUMBER: 26-AS-20201008081416

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: 44	DATE:	05/21/2021
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Ivonne Chavez		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Staff yell at residents
Staff are not giving residents medication per doctor orders
Staff was smoking in the facility

INVESTIGATION FINDINGS:

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Licensing Program Analyst Marybeth Donovan (LPA) conducted an unannounced visit to deliver the complaint investigation findings. LPA met with Ivonne Chavez Med Tech.

A virtual tour was conducted on 10/15/2020 and between 10/15/2021 through 5/9/2021 LPA interviewed: Administrator, 5 staff and 6 residents.

5 out of 5 residents denied: seeing staff yell at residents , experienced medication issues/ errors, and or seeing any staff smoking within the facility

1 resident declined to participate in the interview process.

5 out of 5 staff denied: any staff yelling at residents, medication error/ issues, and any staff smoking within facility.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth Donovan	TELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2021

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 6

Control Number 26-AS-20201008081416

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: SOUTH COUNTY RETIREMENT HOME INC.	FACILITY NUMBER: 435294143
	VISIT DATE: 05/21/2021

NARRATIVE

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Administrator stated that staff never yells at residents but will instead redirect when necessary to ensure the health and safety of resident. Stated all medications are passed out on time and accordingly per Physician’s Orders. Additionally, no staff smokes inside the facility.

LPA reviewed documents received from 10/15/2020 through 5/9/2021. The documents reviewed includes but are not limited to: admission agreement, Medication Administration Records (MARS), staff and resident rosters, training records, staffing schedule for 10-1 through 10-15-2020 and maintenance records/ cleaning schedules.

LPA did not find any irregularities among the data. A review of MARS indicates no documentation of any medication error, staffing schedule was consistent, no mention of any drug impropriety-including no smoking inside the facility in staffing records, and no records of staff being unprofessional.

The Department has investigated the above allegations. Based on LPA inspection, observations, records review, interviews with AD, staff, and residents, the preponderance of evidence standard has not been met therefore the allegations are UNSUBSTANTIATED. Meaning although the allegationsmay have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

No deficiencies were cited per the California Code of Regulations, Title 22, as a result of this complaint investigation.

LPA reviewed report with Ivonne Chavez Med Tech and provided a copy of the report.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth Donovan	TELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/08/2020 and conducted by Evaluator Marybeth Donovan

COMPLAINT CONTROL NUMBER: 26-AS-20201008081416

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: 44	DATE:	05/21/2021
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Ivonne Chavez		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Staff did not ensure facility was pest free

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Marybeth Donovan conducted an unannounced visit to deliver the complaint investigation finding. LPA met with Ivonne Chavez Med Tech.

A virtual tour was conducted on 10/15/2020 and between 10/15/2020 through 5/9/2021 LPA interviewed: Administrator, 5 staff and 6 residents.

5 out of 5 residents denied: seeing any pests and/ or bed bugs within the facility.
1 resident retracted consent and refused to conduct interview process.
5 out of 5 staff denied:seeing/ knowing any pest and or bed bug issues.

Per AD, staff noticed bedbugs at the facility on 10/3/2020; specifically, in one of the living room area. Regular cleaning and deep cleaning commenced immediately.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth Donovan	TELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 26-AS-20201008081416

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: SOUTH COUNTY RETIREMENT HOME INC.	FACILITY NUMBER: 435294143
	VISIT DATE: 05/21/2021

NARRATIVE

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AD stated that deep cleaning involves but are not limited to: vacuuming, washing and drying in high heat for longer periods. AD stated that, facility engages in cleaning the facility daily and a weekly deep cleaning procedure. Additionally, bedbugs spray, bedbugs’ powder and a heat gun were used to kill, clean the affected area. On 10/4/2020, the couches in the affected living room were disposed. After cleaning and infection eradication measures were taken, AD inspected the area to ensure that the area was pest free.

LPA reviewed documents received from 10/15/2020 through 5/9/2021. The documents reviewed includes but are not limited to: admission agreement, Medication Administration Records (MARS) staff and resident rosters, training records, staffing schedule for 10-1 through 10-15 and maintenance records/ cleaning schedules.

Invoices from professional pest control company indicates that the company goes out every 3 months to conduct preventive spraying for pest control. Invoices reviewed do not note any bed bug activity in the facility.

The Department has investigated the above allegation. Based on interviews, review of records, the Department has found that the complaint allegations are UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. No deficiencies were cited per the California Code of Regulations, Title 22, as a result of this complaint investigation.

Exit interview conducted with Samuel Apostol Adminstrator and Ivonne Chavez Med Tech and a copy of this report provided.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth Donovan	TELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2021

LIC9099 (FAS) - (06/04)

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