405800061-7-11-2023-29-AS-KBUY-CW6366-20230929175749

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405800061
Report Date: 07/11/2023
Date Signed: 07/11/2023 01:12:26 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
07/05/2023 and conducted by Evaluator Darlene Chavez

COMPLAINT CONTROL NUMBER: 29-AS-20230705155053

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:	07/11/2023
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Joni Chapman, Administrator		TIME COMPLETED:	01:25 PM

ALLEGATION(S):

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Client in care sustained unexplained injuries while in care
Staff do not allow visitation in client's room
Staff do not allow client in care to leave the facility
Staff do not ensure client in care is adequately dressed

INVESTIGATION FINDINGS:

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On 7/11/23 at 10:15 am, Licensing Program Analyst (LPA) Chavez conducted an unannounced 10-day complaint visit to the facility listed above. LPA met with Joni Chapman, Administrator, and explained the purpose of the visit. Also in attendance was Miguel Morin, Quality Assurance Specialist with Tri-Counties Regional Center.

On the allegation, “Client in care sustained unexplained injuries while in care,” the complainant was concerned that Client #1 (C1) had scratches on their arms. To investigate, LPA interviewed the administrator and staff. The administrator states that C1 has Self-Injurious Behaviors (SIB) and tries to bite their forearms. Administrator showed LPA gloves and explained that these are used on C1 to cover C1’s arms to prevent C1 from biting their arms. Administrator says that C1 had bitten their arms at times when the gloves are not worn and there may have been marks that appeared as scratches. C1 was not in the facility today, however, Administrator provided photos of C1 today. Continued on 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023

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-20230705155053

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: 07/11/2023

NARRATIVE

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The photos show 2-3 red marks approximately the size of a pencil eraser on each arm and a scab a bit smaller than a dime on the left outer elbow. Administrator says these are caused by C1 pinching or trying to bite their arms. Based on the evidence obtained, the allegation, “Client in care sustained unexplained injuries while in care,” is deemed Unsubstantiated at this time.

On the allegation, “Staff do not allow visitation in client's room,” the complainant’s concern was that visitors for C1 were not allowed to visit in their bedroom and only allowed to visit in common areas of the facility during a visit in June 2023. LPA interviewed the administrator and reviewed records. The administrator states that the facility’s Visitor Policy instructs visitors that “All visits should be conducted in a common area of the house…” Administrator says that this is communicated to all visitors and was recently enforced with C1’s visitor and other clients’ visitors. LPA reviewed the Visitor Policy signed by C1’s visitor in June 2023 which shows this statement. Based on evidence obtained, the allegation, “Staff do not allow visitation in client’s room,” is deemed Unsubstantiated at this time.

On the allegation, “Staff do not allow client in care to leave the facility,” the complainant’s concern was that C1 is “never allowed to leave the facility.” LPA interviewed the administrator and staff and made observations. Administrator states that C1 is allowed to leave the facility and has attended day program Monday through Friday since May 2017. Staff interviewed state they were taking C1 to day program today. LPA observed C1 being transported. Based on the evidence obtained, the allegation, “Staff do not allow client in care to leave the facility,” is deemed Unsubstantiated at this time.

On the allegation, “Staff do not ensure client in care is adequately dressed,” the complainant was concerned that C1 was dressed in heavy clothing during a hot day in June 2023 when C1 had a visitor. LPA interviewed the administrator and staff and made observations. The administrator says she was not present during C1’s visit in June 2023, however, the back-up administrator, Jami West, was present. LPA spoke with back-up administrator who says that during the visit, it was cool in the house even though it was hot outside. She says C1 was wearing a light-weight, long-sleeve jersey shirt with matching leggings. LPA observed the outfit worn that day which appeared light-weight and appropriate for the recorded temperature that day. LPA observed the temperature in the facility on today’s visit and although the temperature was 78F it felt cooler. Based on the evidence obtained, the allegation, “Staff do not ensure client in care is adequately dressed,” is deemed Unsubstantiated at this time.

Exit interview conducted, report given.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023

LIC9099 (FAS) - (06/04)

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