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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294143
Report Date: 12/15/2021
Date Signed: 12/15/2021 03:25:01 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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
ADMINISTRATOR:APOSTOL, SAMUEL C.FACILITY TYPE:
740
ADDRESS:460 CHURCH AVENUETELEPHONE:
(408) 683-0229
CITY:SAN MARTINSTATE: CAZIP CODE:
95046
CAPACITY:46CENSUS: 45DATE:
12/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Samuel ApostolTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Samuel Apostol.

During visit, LPA Marrufo toured the facility inside and out. LPA Marrufo observed a visitor screening area at the entrance. LPA Marrufo toured the facility kitchen, pantries, and refrigerators and observed a perishable food supply of at least 3 days and a non-perishable food supply of at least 7 days. LPA Marrufo observed a PPE supply of at least 30 days. LPA Marrufo observed COVID-19 related posters throughout the facility hallways. The facility bathrooms has available soap and paper towels and hand washing signs.

LPA Marrufo toured the outside area and observed the exits to be clear of obstructions.

No deficiencies were cited as per California Code of Regulations Title 22.

This report was reviewed with Samuel Apostol and a copy of the report was provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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