405800061-10-31-2025-29-AS-RDLN-DMYQ98-20251031115755

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405800061
Report Date: 10/31/2025
Date Signed: 10/31/2025 11:58:02 AM

Document Has Been Signed on 10/31/2025 11:58 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:	10/31/2025
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:11 AM
MET WITH:	Joni Chapman		TIME VISIT/ INSPECTION COMPLETED:	12:05 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 conducted a case management incident visit to facility above. LPA met with Administrator and explained the purpose of the visit. LPA received a call from the facility Administrator stating R1 had a change of condition on 09/03/2025 and was not walking in R1's normal way, Administrator made a doctors appointment for 09/03/2025 and the doctor ordered Physical Therapy (PT) 2 x per week, a gait belt and a return visit in 2 weeks to see the doctor if R1 was still not walking normally. PT visited on 09/04/2025 and worked with R!1. On 09/08/2025 Administrator took R1 to the emergency room because R1 could not bear any weight. Administrator stated to the nurse that it seemed to be coming from R1's knees or legs the way R1 was standing was not normal for R1. The ER did testing and x-rays but did not do one of R1's knees the ER checked R1's tailbone, hips, and pelvis area only and found no injuries and discharged R1 back to the facility. On 09/10/2025 R1 was seen by PT again, working on walking, stability and strengthening of R1's legs, On 09/11/2025 Administrator had a phone call with primary care physician for R1 regarding R1 could not walk or hold R1's weight, Physician provided a referral for R1 to go to a Skilled Nursing Facility (SNF) for rehabilitation, as the home is an Ambulatory home only. The same day R1 had PT again. Administrator called all SNF's to see if they would do an intake for the referral. Administrator was told that the only way they can accept R1 was from a ER/hospital referral.

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Rachael De Leon
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 10/31/2025

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Administrator took R1 on 09/12/2025 to the ER for evaluation for placement in the SNF. R1 was admitted to the hospital and kept for 40 days and discharge called Administrator on 10/23/2025 that R1 was being discharged back to the facility, Administrator said she needed a new LIC 602A physicians report stating R1 was Ambulatory in order to take R1 back to facility, Discharge provided the LIC 602A with R1 having ambulatory status. Executive Director and Facility staff picked up R1 from the ER and took R1 back to the facility. R1 was not walking well upon return so all staff were informed R1 was still not able to walk on own and staff needed to provide R1 with extra help. On the same day 10/23/2025 R1 used the restroom, staff stood outside the bathroom door and waited for R1 to call from help, R1 stood up on own and opened the bathroom door stating R1 needed help with pulling up pants, at the same time R1's knees buckled and R1 twisted and went down as staff went to assist R1. R1 was hurt and staff called 911. R1 was taken to the ER and admitted to a different hospital and has remained there since 10/23/2025. R1 has a fractured left lower tibia and had surgery on 10/24/2025 and has remained in the hospital. Hospital is looking for a SNF for rehabilitation.

Administrator and staff recognized the change in condition immediately got R1 in to doctor, when R1 was not showing any improvement the facility administrator called for a referral, upon SNF not accepting R1 was taken to the ER, when released from the ER the doctors provided a new LIC 602 A with ambulatory status, R1 returned still not able to bare weight and R1 had a fall and 911 was called immediately and R1 went to a different hospital and was admitted. The facility and staff followed policy and procedures for R1.

Exit interview conducted and copy of report printed for Administrator.

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Rachael De Leon
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2025

LIC809 (FAS) - (06/04)

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