435294143-9-30-2021-26-AS-KHOS-C7QNHG-20211012102843

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435294143
Report Date: 09/29/2021
Date Signed: 09/30/2021 03:17:39 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
10/12/2020 and conducted by Evaluator Steve Nguyen

COMPLAINT CONTROL NUMBER: 26-AS-20201012163057

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: 41	DATE:	09/29/2021
		UNANNOUNCED	TIME BEGAN:	11:25 AM
MET WITH:	Samuel Apostol		TIME COMPLETED:	12:10 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff withdrew blood from residents
Staff administered incorrect medications to residents

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Steve Nguyen conducted an unannounced visit to deliver the complaint investigation finding. LPA met with Administrator (AD) Samuel Apostol.

On 10/13/2020, Licensing Program Analyst (LPA) Steve Nguyen interviewed complainant. Complainant denied ever making such allegations and asked allegations to be retracted.

On 10/15/2020, LPA conducted a virtual tour of facility with AD: Observed medication is locked, cleaning supplies locked, sharps are locked, all staff wearing masks and the practice of social distancing in use. LPA requested the following documents but not limited to: staff roster, resident roster, MARs, and a list of residents that received blood work for the month October 2020.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Steve Nguyen	TELEPHONE: (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-20201012163057

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

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

On 10/15/2020, LPA interviewed AD. Per AD: All residents go to County Lab or Home Health for blood work. AD denies any medication error within the facility for the month October 2020.

On 10/30/2020, LPA interviewed 4 Staff. 4 out of 4 staff denied that facility carries out blood work on premises. 4 out of 4 staff denied any medication error for the month of October 2020.

On 10/30/2020, LPA interviewed 4 residents. 3 out of 4 residents stated that they go to clinic or hospital for blood work. 1 out of 4 stated that he/she don’t need blood work. 4 out of 4 residents stated that they get their medication on time and have no knowledge of any errors.

LPA reviewed Home Health Lab Work. Home Health Lab Work indicated that residents get their blood work done at Home Health and not at South County Retirement Home INC.

LPA reviewed Medical Assessment Records (MARS): All documents were complete and there were no missing data.

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 Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Steve Nguyen	TELEPHONE: (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