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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435294143
Report Date: 11/10/2025
Date Signed: 11/10/2025 11:29:35 AM

Unsubstantiated


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
09/30/2025 and conducted by Evaluator Maria Partoza
COMPLAINT CONTROL NUMBER: 26-AS-20250930142518

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: DATE:
11/10/2025
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:TIME COMPLETED:
11:15 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff dispensing medication is under the age of 18 years old
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
This is a continuation of the LIC 9099 report

On 10/3/2025, LPA Mita Partoza, reviewed the record and observed that the staff was given training for medication administration. Based on interview of staff 1 (S1), S1 stated that staff 2 (s2) was given medication administration training. S1 stated that S2 is not alone during the time of medication pass. Based on review of document, S2 is under the age of 18 and is a staff. S1 stated that S2 comes to the facility after school and arrives at around 4:00 and 4:30 p.m. to help out at the facility. S1 stated and S4 stated that S2 does not dispense medication by himself/herself. S1 stated that S2 accompanies S4 and S5, who are the regular medication technicians at the facility during medication pass, but does not dispense medication.

Page 3 of 4
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 26-AS-20250930142518
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: 11/10/2025
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
26
27
28
29
30
31
32
Based on document review and interviews although the allegation that facility staff dispensing medication is under the age of 18 years old could have happened the preponderance of evidence have not been met and therefore the allegation is unsubstantiated.

No deficiencies were cited during today's visit based on the California Code of Regulations (CCR) Title 22. An exit interview was conducted with Licensee/Administrator Samuel Apostol and a copy of the report was provided.

End of Report



page 4 of 4
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4