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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405800061
Report Date: 01/26/2023
Date Signed: 01/26/2023 01:49:22 PM

Document Has Been Signed on 01/26/2023 01:49 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 HOUSEFACILITY NUMBER:
405800061
ADMINISTRATOR:JONI CHAPMANFACILITY TYPE:
735
ADDRESS:13600 SAN ANTONIOTELEPHONE:
(805) 466-6274
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY: 6CENSUS: 6DATE:
01/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:41 AM
MET WITH:Joni Chapman, AdministratorTIME COMPLETED:
02:05 PM
NARRATIVE
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On 1/26/2023 at 11:41 am, Licensing Program Analyst (LPA) Chavez conducted an unannounced annual infection control inspection of the facility above. LPA met with Joni Chapman, Administrator, and explained the purpose for the visit.

LPA toured the facility with the administrator and observed the following: LPA was screened upon entry to the facility. Staff are wearing masks. The facility has infection control signage. LPA observed fire extinguishers (2) in the hall near administrator’s office and the kitchen. The extinguishers are fully charged and were inspected on 11/22/22. Each resident bathroom (3) has soap dispensers. Administrator states paper towels are provided to clients when using the restroom as clients otherwise have, in the past, thrown the towels in the toilet. At 12:03 pm, LPA observed the temperature in the kitchen freezer at 12F degrees and the temperature in the laundry room freezer at 5F degrees. Regulation is that freezer temperatures shall be at zero degrees Fahrenheit. Deficiency cited. At 12:25 pm, LPA observed a torn area of the screen door at the backyard sliding glass door. The tear is approximately four inches by twelve inches. Licensee will repair the screen, take a photo, and send to LPA by 2/2/23.

At 12:45 pm, LPA conducted the Infection Control mitigation module with the administrator.

Exit interview conducted, deficiency cited and the report and appeal rights emailed to the executive director and the administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2023
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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Document Has Been Signed on 01/26/2023 01:49 PM - It Cannot Be Edited


Created By: Darlene Chavez On 01/26/2023 at 01:40 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: C.A.L.L.-SAN ANTONIO HOUSE
FACILITY NUMBER: 405800061

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
85076(d)(2)
85076(d)(2) Food Service: (d) The licensee shall meet the following food supply and storage requirements:
(2) Freezers shall be large enough to accommodate required perishables and shall be maintained at a temperature of zero degrees F (17.7 degrees C). This requirement was not met as evidenced by:
Deficient Practice Statement
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Based on observations, the facility did not maintain a zero F degrees temperature in the two freezers which poses an immediate health and safety risk to residents in care.
POC Due Date: 01/27/2023
Plan of Correction
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Administrator will ensure that freezers are adjusted immediately to zero degrees F. Administrator will take a photo of the thermometers in the freezers, and send to LPA by 1/27/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Kelly Burley
LICENSING EVALUATOR NAME:Darlene Chavez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2023


LIC809 (FAS) - (06/04)
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