435294143-11-15-2021-26-AS-KHOS-C9GKPQ-20211207070507

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435294143
Report Date: 11/15/2021
Date Signed: 11/15/2021 04:01:06 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
07/27/2021 and conducted by Evaluator Steve Nguyen

COMPLAINT CONTROL NUMBER: 26-AS-20210727112127

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: 43	DATE:	11/15/2021
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Samuel Apostol		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Facility did not follow COVID screening protocols
Facility equipment is in disrepair
Facility did not offer activities for the resident

INVESTIGATION FINDINGS:

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

On 7/27/2021, Department received complaint with above allegations and on 7/30/2021, Licensing Program Analyst, Marybeth Donovan opened the complaint.

On 7/30/2021, LPA Marybeth Donovan, conducted a tour of facility with AD: Observed that facility has a screening protocol that was enforced. Exterior gate signs clearly indicated that all visitor are to call for assistance. Facility is clean. That watering hose was functional. Activity calendar posted on wall in hallway and any changes or modified activity was reflected in second copy next to original. VCR in R1’s room was not connected to TV and R1 stated that resident did not inform facility of interruption of functionality. AD is aware and will have staff member look into VCR status immediately.

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: 11/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2021

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

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20210727112127

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: 11/15/2021

NARRATIVE

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On 9/29/2021, LPA Steve Nguyen, conducted a tour of facility with AD: Observed that screening protocol was enforced and that there was signage for covid mitigation posted throughout facility in prominent vantage points. Facility was clean. Watering hose was functional and were used by staff and residents for gardening activities. Observed VCR in residents’ room was functional. AD stated that, residents like to watch videos in their room.

On 7/30/2021, LPA Marybeth Donovan interviewed 2 staff and 1 resident. 2 out of 2 staff denied all allegations. Per staff: Covid Mitigation process strictly enforced, and signage is up. Watering hose is functional. Once informed of VCR status, facility took immediate action. Resident is not sure on any of the allegations and not sure if VCR is not connected or just not working.

LPA Marybeth Donovan reviewed the Activities calendar. Noted that any modification is reflected on the copy posted next to original. Per AD, facility tries to follow calendar whenever possible.

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: 11/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2021

LIC9099 (FAS) - (06/04)

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