South County Retirement Home Inc.

Licensing Program Analyst (LPA) Monter conducted an unannounced complaint investigation to deliver the findings on the above allegations. LPA met with Administrator Samuel Apostol. On August 26, 2024, the Department received a complaint alleging Facility staff withholding prescribed medication causing resident to be hospitalized. It has been alleged that that facility staff withheld R1’s medication. On September 5, 2024, Licensing Program Analyst Manuel Monter interviewed 5 residents. (R2-R6). 5 Out of 5 Residents interviewed stated they get their medication everyday & staff does not withhold residents’ medications. Page 1 Out of 4. UnfoundedRead the full finding— CDSS inspection report, November 15, 2024 · control 26-AS-20240826154515

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced visit to deliver findings regarding the allegation listed above. LPA met with facility Administrator (ADM) Samuel Apostol. On May 9, 2024, the Department received a complaint alleging Facility staff did not prevent physical altercation between residents. It has been alleged that resident R2 pushed R1. On May 16, 2024, LPA Monter interviewed residents R1-R13. 1 Out of 13 residents interviewed (R1) stated R2 had pushed R1. 4 Out of 13 residents interviewed (R2, R4, R5, R12) stated R2 did not push R1 and R1 had bumped into R2, causing R1 to fall. 8 Out of 13 residents (R3, R6-R11, R13) stated they did not see the alleged altercation between R2 and R1. Page 1 Out of 3. UnfoundedRead the full finding— CDSS inspection report, June 7, 2024 · control 26-AS-20240509125227

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced visit to deliver findings regarding the allegation listed above. LPA met with facility Administrator (ADM) Samuel Apostol. This Report is beng amended and the findings are being changed from Unfounded to Unsubstantiated due to new information. On April 19, 2024 the Department received a complaint alleging Staff did not allow resident to have a private visitation. On April 26, 2024, LPA's interviewed residents R1-R10. 8 Out of 10 residents inteviewed (R2-R3, R5-R10) stated the facility provides them with privacy, when having visitors. R1 & R4 stated they did not know if they had privacy. On April 26 & May 2,2024 LPA interview facility ADM. ADM stated the staff are instructed to give the residents and their case managers space if they are requesting privacy. ADM stated if the case manager asks staff member for privacy, then staff will give the resident and their case manager privacy. ADM confirmed if residents are talRead the full finding— CDSS inspection report, April 26, 2024 · control 26-AS-20240419161735

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced visit to deliver findings regarding the allegation listed above. LPAs met with facility Administrator (ADM) Samuel Apostol. On 08/25/2022 the department received a complaint alleging that a resident fell and sustained an injury. It has also been alleged that staff did not seek timely medical attention for a resident. The investigation revealed either 08/20/2022 or 08/21/2022 during the night shift, a resident living at the facility (R1) was searching for cigarette buds in the facility’s backyard and had an unwitnessed fall around 0600 hours. A staff member (S1) brought R1 inside of the facility and placed him/her in a wheelchair. S1 assessed R1 for pain wherein R1 stated he/she was fine. S1 stated R1 was able to lift his/her left leg while the right leg hurts. S1 informed staff S2 that R1 fell outside. Page 1 out of 3 SubstantiatedRead the full finding— CDSS inspection report, October 19, 2023 · control 26-AS-20220825122345

Licensing Program Analyst (LPAs) Manuel Monter conducted an unannounced visit to deliver findings regarding the allegation listed above. LPA met with facility Administrator (ADM) Samuel Apostol. On October 24, 2022 the department received a complaint alleging that a resident fell and sustained an injury. It has also been alleged that staff did not seek timely medical attention for resident. The investigation revealed either 08/20/2022 or 08/21/2022 during the night shift, a resident living at the facility (R1) was searching for cigarette buds in the facility’s backyard and had an unwitnessed fall around 0600 hours. A staff member (S1) brought R1 inside of the facility and placed him/her in a wheelchair. S1 assessed R1 for pain wherein R1 stated he/she was fine. S1 stated R1 was able to lift his/her left leg while the right leg hurts. S1 informed staff S2 that R1 fell outside. Page 1 out of 3 SubstantiatedRead the full finding— CDSS inspection report, October 19, 2023 · control 26-AS-20221024102823

Licensing Program Analyst (LPA) Manuel Monter & Mita Partoza conducted an unannounced visit to deliver findings regarding the allegation listed above. LPAs met with facility Administrator (ADM) Samuel Apostol. On 10/02/2023 the department received a complaint alleging that a resident sustained mental/verbal abuse from staff and residents. On 10/10/2023, LPA's interviewed R1. R1 stated the staff are not teasing, taunting, or saying mean things to him/her. R1 stated the female residents are teasing him/her regarding his/her girlfriend. R1 stated this is due to jealously. LPA asked R1 who was teasing him/her, R1 stated he/she did not know. Page 1 out of 2 UnfoundedRead the full finding— CDSS inspection report, October 10, 2023 · control 26-AS-20231002152059

On 6/22/23, LPAs Monter and Rai and LPM Manzano conducted an unannounced complaint investigation of the above allegation and met with Administrator, Sam Apostol. On 6/22/23, LPA's interviewed R1 regarding the alligation above. R1 stated intially did not want to talk about it. R1 then stated that it may have been S1 or may have been his/her room mate. When ever LPA attmepted additional questions, R1 would digress and talk about something unrelated. R1 when asked her/his thoughts on S1, R1 stated they are fine. S1 was interviewed and denied the alligation. When questioned further, R1 stated S1 didnt inapprotriatley touch him/her, but their roomate did. R1's roomate was interviewed and R2 stated touching never occured with R1. R2 stated S1 does not assit with shower or enters their room. Page 1 out of 2 UnsubstantiatedRead the full finding— CDSS inspection report, June 22, 2023 · control 26-AS-20220623103245

On 6/22/23, LPAs Monter and Rai and LPM Manzano conducted an unannounced complaint investigation of the above allegation and met with Administrator, Sam Apostol. Facility staff does not take residents to scheduled medical appointments: LPA's observed facility log regarding medical appointments. Photographs were taken regarding medical appointments for the month of November & December 2021. During a previous visit, over 10 residents were interviewed and asked if the facility takes them to their appointments. 10 out of 10 residents stated the facility does take them to their medical appointments. Page 1 out of 2 UnfoundedRead the full finding— CDSS inspection report, June 22, 2023 · control 26-AS-20211213152254

On 6/22/2023, LPAs Monter and Rai and LPM Manzano conducted an unannounced complaint investigation of the above allegation and met with Administrator, Sam Apostol. On 10/24/2022, Community Care Licensing Division (CCLD) received a complaint with the above allegations. On 10/24/2023, the initial investigation visit was conducted. The Department obtained staff training documents, a staff and resident roster, and staff schedule for the months of September and October of 2022. Page 1 out of 2, see continuation on LIC 9099-C (Page 2). Unsubstantiated— CDSS inspection report, June 22, 2023 · control 26-AS-20221024102823

On 06/07/2023, the Department conducted investigation/infection of the facility and staff on the alleged complaint. Facility faling to safeguard residents property On 06/07/2023, Based on investigation, LPM interviewed Staff (S1), S1 stated that he/she works every Sunday, Tuesday and Wednesday as one of the laundry staff. S1 stated that he/she along with other two staff responsible for the laundry are labeling residents' clothings. S1 stated that there are clothes in the laundry room wherein with no labels. During inspection of the laundry room along with S1, LPM noted that there were more than 20 men and females clothes from sweater, tee-shirts, and pants with no labels. SubstantiatedRead the full finding— CDSS inspection report, June 7, 2023 · control 26-AS-20230518132420

On 6/7/2023, LPAs Monter and Rai and LPM Manzano conducted an unannounced complaint investigation of the above allegation and met with Administrator, Sam Apostol. On 12/1/2021, Community Care Licensing Division (CCLD) received a complaint with the above allegations. On 12/9/2021, the initial investigation visit was conducted. The facility interior and exterior including the TV room, shower rooms, resident rooms, hallways, kitchen, laundry room, smoking area, and backyard was inspected. Medication Audit for R1 - R2 was conducted and MedTech on duty was interviewed. The facility provided a copy of facility's resident roster, staff schedule, resident shower log, visitor log sign-in sheet, and R1-R2s medication log. Page 1 out of 3, see continuation on LIC 9099-C (Page 2). UnfoundedRead the full finding— CDSS inspection report, June 7, 2023 · control 26-AS-20211201154803

On 6/7/2023, LPAs Monter and Rai and LPM Manzano conducted an unannounced complaint investigation of the above allegation and met with Administrator, Sam Apostol. Based on allegation, facility did not have enough saff to meet resident's needs since appears they are just housing people and not actually caring for them. During today's inspection, Administrator and 5 staff members were observed on the premise. Based on random interviews with residents and staff, staff are available to help and assist with tasks. Based on the interviews conducted with clients and staff and based on observation and records review, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED. NoRead the full finding— CDSS inspection report, June 7, 2023 · control 26-AS-20211201154803

On 6/7/2023, LPAs Monter and Rai and LPM Manzano conducted an unannounced complaint investigation of the above allegation and met with Administrator, Sam Apostol. During complaint investiagtion on 05/19/23, LPA toured the faciltiy and observed cigarette buds scattred in the front yard and backyard smoking area. Broken chair was observed in the front yard. LPAs and LPM observed broken blinds in residents' rooms. LPA Monter observed the floor of R1's room #5 to have a slight indentation directly at the entrance which may pose as a tripping hazard for the resident. During today's complaint investigation, LPA's observed broken chairs and appliances (stove) in the front yard. The garbage bin in the front yard was not covered, exposing the garbage which attrached a swarm of 10-12 flies to the container. LPAs and LPM observed a pile of flattened cardboard boxes next to the garbage bin. Page 1 out of 2, see continuation on LIC 9099-C (Page 2). SubstantiatedRead the full finding— CDSS inspection report, June 7, 2023 · control 26-AS-20211201154803

On 06/07/23, LPA's conducted a complaint investigation regarding the alligations above. LPA's interviewed resident R1 and R2 regarding residents being locked in their rooms during covid out break. R1 stated the faciility did close the door, but does not remember if they locked it. R2 stated they were not locked in their bedroom. ADM stated the facility sent incident report to CCL reporting covid outbreak. CCL recived an incident report regarding the covid outbreak on 02/04/2022. Based on the interviews conducted with clients and records review, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED. UnsubstantiatedRead the full finding— CDSS inspection report, June 7, 2023 · control 26-AS-20220208091354

On 6/7/2023, LPAs Monter and Rai and LPM Manzano conducted an unannounced complaint investigation of the above allegation and met with Administrator, Sam Apostol. During complaint investiagtion on 05/19/23, LPA toured the faciltiy and observed cigarette buds scattred in the front yard and backyard smoking area. Broken chair was observed in the front yard. LPAs and LPM observed broken blinds in residents' rooms. LPA Monter observed the floor of R1's room #5 to have a slight indentation directly at the entrance which may pose as a tripping hazard for the resident. During today's complaint investigation, LPA's observed broken chairs and appliances (stove) in the front yard. The garbage bin in the front yard was not covered, exposing the garbage which attrached a swarm of 10-12 flies to the container. LPAs and LPM observed a pile of flattened cardboard boxes next to the garbage pin. Page 1 of 2. Continuation, see page 2, LIC9099-C SubstantiatedRead the full finding— CDSS inspection report, June 7, 2023 · control 26-AS-20220422141525

On 06/07/2023, LPA's conducted a complaint investigation regarding the alligations above. Based on allegation that on 6/15/2022 the facility indoor was at 82 degrees F. Some residents alleged it was hot that night and asked staff if they could turn on AC but staff refused. Based on San Martin weather.com on 6/15/2022, the tempreture of the area was a high of 91F and a low of 54 degrees F. LPA's interviewed more or less 10 residents. No resident complained about the facility's tempreture. R1 stated the temperature can get hot but prefers to keep window closed. R2 stated the facility temperature does get hot but they have a fan to mitigate the temperature. ADM stated that if the tempretures get hot; the facility will turn on the AC and provide waters to the residents. ADM stated if a resident complained about the tempreture, then they will adjust the thermostat. UnsubstantiatedRead the full finding— CDSS inspection report, June 7, 2023 · control 26-AS-20220623103245

On 6/7/2023, Based on interview with ADM and Staff (S1), R1 and R2 had a verbal and physical altercation on 07/13/2022 regarding R2's watch. R1 grabbed R2's watch causing a cut on his/her right arm. ADM stated that LIC624 was submitted to CCLD on 7/14/2022. ADM stated that R2's responsible party was notified was notified of this incident according to ADM. Based on record review, CCLD received an incident report of this incident between R1 and R2. Based on investigation, R2 did sustained an injury during an unwitness altercation with R1. ADM stated that first aid was applied but does not require hospitalization. UnsubstantiatedRead the full finding— CDSS inspection report, June 7, 2023 · control 26-AS-20220718115833

On 06/07/2023, LPAs Rai and Monter and LPM Manzano conducted an unannounced complaint investigation of the above allegations and met with Administrator Sam Apostol. Staff confiscated resident property Based on interview with staff, ADM stated that R1 is no longer in the facility. ADM is aware of the incident occurred on 2/22/2023. ADM stated that R1 had a cellphone but staff did not confiscate R1's phone. Staff (S1) stated they do not confiscate resident's personal belongings. ADM denied allegation that R1's cellphone was confiscated. Staff (S1) stated that R1 had a behavior where he/she thew his/her cellphone towards the staff at the facility during the incident on 2/22/2023. Page 1 of 3. Continuation on page 2, LIC9099-C UnsubstantiatedRead the full finding— CDSS inspection report, June 7, 2023 · control 26-AS-20230210140919

On 06/07/2023, LPAs Rai and Monter and LPM Manzano conducted an unannounced complaint investigation of the above allegations. Unlawful Eviction. On 06/07/2023, Based on interview with ADM, ADM stated that facility had an outburst behavior which was out of control. The facility had to call Emergency Psychiatric Services (EPS) and 24 hour care regarding R1's uncontrolled behavioral outburst. ADM stated that EPS came to the facility 2-3 hours later wherein they took R1. R1 was admitted at EPS. Page 1 of 2. Continuation on page 2, 9099-C. Unfounded— CDSS inspection report, June 7, 2023 · control 26-AS-20230210140919

On 5/19/2023, LPAs Monter and Rai and LPM Manzano conducted an unannounced complaint investigation of the above allegation. On 5/19/2023, during today's inspection of the facility, LPAs/LPM observed 10 residents smoking and talking in the backyeard. LPAs and LPM observed swarm of approximately 40 flies forming a large or dense group under the covered patio with patio tables and chairs. Cigarette buds were observed around the cemented ground, an empty can of soda on ground. LPAs observed metled cheese and a peeled orange on the table. An interview with Staff S1 stated the presence of the flies in the facility was due to the horses in the neighborhood. Page 1 out of 2, see continuation on LIC 9099-C (Page 2). SubstantiatedRead the full finding— CDSS inspection report, May 19, 2023 · control 26-AS-20211201154803

On 5/19/2023, LPAs Monter and Rai and LPM Manzano conducted an unannounced complaint investigation of the above allegation. During the tour of the facility, LPAs and LPM observed staff storing medications in a kitchen cabinet which does not have lock. Based on interview with staff S1, S1 was the designated medication technician during day shift. S1 stated during interview that medications for PM and weekend was stored in the cabinet in the kitchen. S1 stated that the doors in the kitchen are locked and the staff have keys to access it. Page 1 of 2, please see LIC 9099-C. Substantiated— CDSS inspection report, May 19, 2023 · control 26-AS-20220623103245

Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced complaint inspection to deliver the findings on the above allegations. LPA met with facility Medical Technician Ivonne Chavez (S1). Administrator Samuel Aposto (Admin) was unable to attend the inspection. Admin gave S1 permission to sign and review the report on his behalf. On 11/22/2021, a resident (R1) was discharged from the hospital and referred to a home health agency. The discharge medical records indicate that R1 had difficulty walking, impaired mobility, and issues with activities for daily living. R1 was assessed by home health and was determined to need support during transfers. R1 was noted to have fall precautions put in place, and was noted to only walk while supervised. Witnesses reported that during visits, they attempted to locate staff to provide this information, but were unable to find staff within the facility. During interviews with staff members, staff stated that R1 was able to ambulate by himRead the full finding— CDSS inspection report, November 22, 2022 · control 26-AS-20220210171405