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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435294143
Report Date: 09/29/2021
Date Signed: 09/30/2021 03:16:25 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
10/26/2020 and conducted by Evaluator Steve Nguyen
COMPLAINT CONTROL NUMBER: 26-AS-20201026145206
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: 41DATE:
09/29/2021
UNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Samuel ApostolTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility staff failed to ensure resident received phone call messages from family
Facility staff member physically abused resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Steve Nguyen conducted an unannounced visit to deliver the complaint investigation finding. LPA met with Administrator (AD) Samuel Apostol.

On 10/30/2020, Licensing Program Analyst (LPA) Steve Nguyen interviewed complainant. Complainant denied ever making such allegations and asked allegations to be retracted.

On 10/30/2020, LPA conducted a virtual tour of facility with AD: Observed medication was locked, cleaning supplies locked, sharps are locked, all staff wearing masks and the practice of social distancing in effect. Noted a pay phone within the facility that's available for resident to use. LPA requested the following documents but not limited to: staff roster, resident roster, and LIC634 (incident reports from June 2020 through October 2020).
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Steve NguyenTELEPHONE: (650) 676-0051
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021
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 2
Control Number 26-AS-20201026145206
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: SOUTH COUNTY RETIREMENT HOME INC.
FACILITY NUMBER: 435294143
VISIT DATE: 09/29/2021
NARRATIVE
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On 10/30/2020, LPA interviewed AD. Per AD: Facility has a pay phone that is accessible to all clients 24/7. All residents know where the pay phone is located and because it is a pay phone, it does not take any messages. AD goes on to state that, to the best of his knowledge, there had not been any incident of staff abusing any residents. The facility provides training in dementia and elder or dependent abuse, to further enhance skill set to assist with residents on an ongoing basis to ensure the health and safety of residents.

On 10/30/2020, LPA interviewed 4 Staff. 4 out of 4 staff stated that there is a pay phone for residents use, and that the pay phone does not take messages. 4 out of 4 staff denied any knowledge of abuse.

On 10/30/2020, LPA interviewed 4 residents. 4 out of 4 residents stated that they know there is a pay phone but does not know anything about missed messages. 4 out of 4 residents denied any abuse from staff.

LPA reviewed LIC 634 Incident Reports from June 2020 through October 2020, and no indications of abuse reported. LPA also reviewed training certificate and staff are trained in elder or dependent abuse.

The Department has investigated the above allegations. Based on interviews, review of records, the Department has found that the complaint allegations are UNFOUNDED, meaning that the allegations were 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.

This report was reviewed with Administrator Samuel Apostol and a copy of this report provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Steve NguyenTELEPHONE: (650) 676-0051
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2