405800061-11-9-2022-29-AS-KBUY-CLFU64-20221123141743

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405800061
Report Date: 11/09/2022
Date Signed: 11/09/2022 12:20:55 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/04/2022 and conducted by Evaluator Darlene Chavez

COMPLAINT CONTROL NUMBER: 29-AS-20221104093005

FACILITY NAME:	C.A.L.L.-SAN ANTONIO HOUSE		FACILITY NUMBER:	405800061
ADMINISTRATOR:	JONI CHAPMAN		FACILITY TYPE:	735
ADDRESS:	13600 SAN ANTONIO		TELEPHONE:	(805) 466-6274
CITY:	ATASCADERO	STATE: CA	ZIP CODE:	93422
CAPACITY:	6	CENSUS: 6	DATE:	11/09/2022
		UNANNOUNCED	TIME BEGAN:	10:57 AM
MET WITH:	Joni Chapman, Administrator		TIME COMPLETED:	12:35 PM

ALLEGATION(S):

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Staff did not assist resident with grooming

INVESTIGATION FINDINGS:

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On 11/9/22 at 10:57 am, Licensing Program Analyst (LPA) Darlene Chavez conducted an unannounced initial 10-day complaint visit to the facility listed above. LPA met with Joni Chapman, Administrator, and explained the purpose of the visit.

To investigate, LPA interviewed the administrator and staff, made observations, and reviewed records. At 10:57 am, the administrator states that on 10/5/22, she took Resident #1 (R1) to the clinic. Staff say they reported redness and swelling on R1’s left ankle to the administrator on 10/4/22. At the clinic, the doctor told the administrator that they didn’t want to touch it and encouraged the administrator to take R1 to the emergency room because it was “too close to bone.” Administrator says she told the doctor “I would rather not because R1 has no insurance.” LPA asked the administrator why clinic staff might consider R1 “unkept and disheveled,” and administrator states that when the clinic doctor instructed her to take R1 to the ER, the administrator’s response may have given the doctor cause to be alarmed. Administrator says she took R1 to the ER directly after leaving the clinic. Continued on 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022

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 29-AS-20221104093005

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: C.A.L.L.-SAN ANTONIO HOUSE	FACILITY NUMBER: 405800061
	VISIT DATE: 11/09/2022

NARRATIVE

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LPA reviewed the ER’s Patient Education & Visit Summary from 10/5/22 which gives a diagnosis of Bursitis of the left ankle. R1 was given antibiotics. Administrator says she took R1 to the podiatrist on 11/9/22, and he also diagnosed it as Bursitis. Administrator and staff state that R1 sits on the ground, indoor and outdoor, on R1’s left side and drags themself across the ground which they believe caused the redness and swelling on R1’s left ankle.

At 11:05 am, LPA observed R1. R1 was wearing casual attire which was in good condition and R1 was groomed but not wearing any footwear. Administrator states that R1 has not worn socks nor shoes since they lived in the facility. She says when staff put footwear on R1, R1 immediately removes them and when staff try again, R1 removes them again. LPA has visited the facility in the recent past and remembers seeing R1 without footwear.

Based on the evidence obtained, the allegation “Staff did not assist resident with grooming,” is deemed Unsubstantiated at this time. There is no evidence staff are not keeping R1 groomed and meeting R1’s needs.

Exit interview conducted and the report emailed to executive director and administration.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022

LIC9099 (FAS) - (06/04)

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