405800061-2-20-2025-29-AS-RDLN-DE3N2C-20250220090431

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405800061
Report Date: 02/19/2025
Date Signed: 02/20/2025 09:07:49 AM

Document Has Been Signed on 02/20/2025 09:07 AM - 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 HOUSE		FACILITY NUMBER:	405800061
ADMINISTRATOR/ DIRECTOR:	JONI CHAPMAN		FACILITY TYPE:	735
ADDRESS:	13600 SAN ANTONIO		TELEPHONE:	(805) 466-6274
CITY:	ATASCADERO	STATE: CA	ZIP CODE:	93422
CAPACITY: 6		CENSUS: 5	DATE:	02/19/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:20 AM
MET WITH:	Joni Chapman, Administrator		TIME VISIT/ INSPECTION COMPLETED:	04:05 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) De Leon arrived at 10:20am 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 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. Physical Plant & Environmental Safety: The facility is a 5 bedroom and 3 bathroom currently occupying 5 residents and employs 13 staff, and 1 Administrator. 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 or mats present. 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 each bathroom sink measured 117.8, 117.5, 117.4 all within regulation requirements. Continued 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 02/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025

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 02/20/2025 09:07 AM - It Cannot Be Edited

Created By: Rachael De Leon On 02/19/2025 at 03:45 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: 02/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80065(f)(4)

Personnel Requirements

(f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance. (4) Assistance with prescribed medications which are self-administered. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records, the licensee did not comply with the section cited above in 1/5 staff did not have annual medication refresher trianing which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/27/2025
	Plan of Correction
1 2 3 4	Licensee agreed to have all staff at the facility trianed in initial or annual medication training for 2025 and provide proof of trianing to LPA with an updated LIC 500 for staff working at the facility.

Type B

Section Cited

HSC

1565(e)

Other Provisions

(e) A facility shall have all of the following information readily available during an emergency: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 5/5 residents did not have emergency packets readily avaiable which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/27/2025
	Plan of Correction
1 2 3 4	Licensee agreed to have emergency packets for each resident in case of emergency have readily avaible to staff on all shifts. Facesheet, Emergency ID and contact information form, Apprisal Needs and services plan or ISP, Medication List, conservator or POA health care records, DNR/POLST, Advanced Health Care Directive, Special Diet precribed by a physician, any recent medical records, make up packets for all 5 residents and send picture to LPA.

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:

Rachael De Leon

LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025

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: 02/19/2025

NARRATIVE

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Operational Requirements: The facility has a current plan of operation 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: Staff have confidential files, 5/6 files were reviewed for finger print clearances, health screening with TB results, Personnel records or applications, Criminal record statements, and 1st Aid & CPR certificates. The administrator file was not at the facility to review.
Personnel Records & Training: Personnel Records were present and kept confidential The facility provides Career Smart 40 hour Initial and 20 hour Continued training of staff at the facility on Disaster & Quarterly Drills, Nutrition, Safety, First Aid, CPR, CPI, Driver Class & Test, Medications, Clients Rights & Mandatory Reporting, Water Safety, and Harassment Prevention as well as training on the Emergency Evacuation Plan, PPE and Infection Control. 1 out of 12 staff were missing at least one of the required training's for 2024-2025. Staff are scheduled to attend training's for 2025.
Clients Rights: The facility conducts annual training on clients rights, personal rights for ARF facilities is posted in the common area of the facility as well as rights with persons with disabilities. 2 out of 12 staff do not have current training and will be scheduled to attend this class.
Clients Records & Incident Reports: The facility keeps resident records confidential. LPA reviewed 5 Resident files for Signed Admission Agreements, Medical Assessments with TB results, Consent Forms, ID and Emergency Information sheet, Safeguard for Personal Property, Appraisal Needs and Services Plans are completed as Individual Service Plans with Tri-Counties Regional Center (TCRC), Personal Rights and Safeguard for Cash Resources all forms were up to date and legible. LPA audited 5 residents P&I Money with ledger, cash and receipts which all balanced.
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. The oven needs to be cleaned and the grease around the stove hood. Continued 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 02/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025

LIC809 (FAS) - (06/04)

Page: 17 of 18

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: 02/19/2025

NARRATIVE

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Health Related Services: The facility makes appointments for the residents for medical and dental care. LPA conducted an audit of 5 residents medications, all medications were stored in original containers, No medication was expired, and no medication labels were altered. The facility handles PRN medications and works with the residents physician if needed. Staff assist residents with self administration of medications.

Incidental Medical Services: The facility provides transportation or assist in providing transportation to medical and dental appointments. The facility does not currently have any residents with restricted or prohibited health conditions. The facility will work with all Home Health Agencies to provide residents care and assistance when ordered by a doctor for those services.

Disaster Preparedness: The facility has a current Emergency& Disaster Plan. The staff are trained on the plan annual and the plan is reviewed and updated if needed on an annual basis. The facility has a plan if needed to be self reliant for 72 hours. The facility has emergency food and water supply, as well as flash lights with batteries. The facility has 3 relocation cites if evacuation is needed. The facility has a current floor plan with emergency evacuation locations. The facility keys are available to all staff on all shifts in case of an emergency. The facility is currently working on making up folders/binders with each residents emergency packets to include resident roster with name, DOB, contact information for doctor, dentist and responsible party, current appraisals or ISP's, medication list, consent forms, and any DNR/POLST or Advanced care directive on file as well as conservator or POA of Health care information on residents. Facility conducts disaster drills quarterly to prepare for several different emergency scenarios.

Emergency Intervention: The facility does not use restraints or seclusion on residents in care. Staff are required to take CPI training and 9 out of 12 need to take the training for 2025.

LPA was not able to interview staff or residents due to being out of the facility at day programs or out in the community.

Exit interview conducted, deficiencies cited, copy of report and appeal rights printed for Administrator.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025

LIC809 (FAS) - (06/04)

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