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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405800061
Report Date: 02/23/2024
Date Signed: 02/23/2024 05:13:29 PM

Document Has Been Signed on 02/23/2024 05:13 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:
02/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Joni ChapmanTIME COMPLETED:
05:20 PM
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Licensing Program Analyst (LPA) De Leon arrived at 3:00pm to conducted a 1 year annual visit to the facility above. LPA met with Administrator Joni Chapman and explained the purpose of the visit.

A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit:

Infection Control: The facility has submitted a current Infection Control Plan to the department. The facility has a sign in and out binder for visitors at entry with hand sanitizer. The bathrooms have toilet paper, paper towels, hand soap, and hand washing signs. The facility has EPA approved disinfectants spray and cleaners. The facility has a 30 day supply of PPE. Quarantined or isolated individuals will have meals and medication delivered to rooms. Staff will be trained on infection control and the use of Personal Protective Equipment (PPE) intially upon hire and annual thereafter. All trash cans and waste baskets have tight fitting covers.

Physical Plant & Environmental Safety: The facility is a 5 bedroom and 3 bathroom currently occupying 6 residents and employs 6 staff, 1 Administrator and 4 on call back up staff if needed. The facility is clean, safe and sanitary. LPA was authorized to enter and inspect facility. The facility has smoke alarms and a carbon monoxide detector. The lighting and lamps are sufficient for the use of the facility and for residents comfort. The showers have non-skid bottom floors. Toilet, hand washing and bathing facilities are operational. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant, cleaning solutions and poisons are inaccessible to residents in care locked in laundry room cupboards, and storage closet. The facility has sufficient space inside and outside for activities and visiting. The facility has a backyard for client use with plenty of shade. The facility has telephone and internet service for resident use. Water temperatures were checked at kitchen sink measured 116.8 and in one the resident bathroom 116.6 F both within regulation requirements. Continued 809-C
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE: DATE: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 02/23/2024
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Operational Requirements: The facility has a current plan of operation and infection control plan on file with the department. The Facility is operating in compliance with the granted fire clearance. The facility has exiting door alarms, video surveillance and self closing, self latching gate with fencing all the way around the back yard. The facility is approved for a capacity of 6 Ambulatory.

Staffing: LPA will return to complete the annual visit.
Personnel Records & Training: LPA will return to complete the annual visit.
Clients Rights: LPA will return to complete the annual visit.
Clients Records & Incident Reports: LPA will return to complete the annual visit.

Food Service: The facility handles and prepares food safely. The facility has 2 day perishables and 7 day non-perishables to meet the food service requirement. The freezer is kept at 0 degrees and the refrigeration is kept at 45 degrees or lower. All food is covered, stored and marked appropriately. Food, snacks and drinks are available when the residents want them. Emergency supply of food and water is available. A menu is posted for residents in care. Cleaning solutions and equipment are stored separately than food supply. Kitchen areas are kept clean and free from litter, rodents, vermin and insects. Kitchen staff are observed for personal hygiene and food sanitation practices.

Health Related Services: LPA will return to complete the annual visit.
Incidental Medical Services: LPA will return to complete the annual visit.
Disaster Preparedness: LPA will return to complete the annual visit.
Emergency Intervention: LPA will return to complete the annual visit.
LPA will conduct interviews with 2 Staff and 2 Residents upon return.

Exit interview conducted and copy of report printed for Administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024
LIC809 (FAS) - (06/04)
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