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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405800061
Report Date: 08/24/2023
Date Signed: 08/24/2023 11:25:08 AM

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
07/05/2022 and conducted by Evaluator Darlene Chavez
COMPLAINT CONTROL NUMBER: 29-AS-20220705102920
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:
08/24/2023
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Kylan Reynoso, Back-up AdministratorTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Resident sustained injuries while in care
Staff are overmedicating resident
Staff are not providing a comfortable environment for resident
Staff are not providing adequate food service to resident
Resident has gained an excessive amount of weight
Staff are not providing hygiene products for resident
Staff are retaliating against residents authorized representative for filing a previous complaint
Facility picnic bench is in disrepair
Facility yard is full of debris
INVESTIGATION FINDINGS:
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On 8/24/23 at 9:45 am, Licensing Program Analyst (LPA) Chavez conducted an unannounced follow-up complaint visit to investigate a complaint dated 7/5/2022. LPA met with Kylan Reynoso, Back-up Administrator, and explained the reason for the visit.

On the allegation, “Resident sustained injuries while in care,” the complainant’s concern was that Client #1’s (C1) neck may be broken since they tried to lift it, and it “just flopped down.” LPA interviewed the administrator and staff, made observations and reviewed records.

On 7/13/22 at 9:45 am, LPA interviewed Joni Chapman, Administrator. Administrator states that C1 does not have a neck injury and there has not been a change in condition to C1’s neck. Administrator says the last in-person doctor’s visit C1 had was in 2019 prior to the pandemic. Staff say they have not seen any injuries with C1’s neck and they would have reported it to the administrator, if they had.
Continued on 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 29-AS-20220705102920
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: 08/24/2023
NARRATIVE
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On 7/13/22, LPA reviewed incident reports and complaints for January 2022 through July 2022. There were no injuries reported by the facility and no complaints regarding injuries to clients in care. On 7/13/22 and 8/24/23, LPA observed clients and did not find visible injuries. Based on the evidence obtained, the allegation, “Resident sustained injuries while in care,” is Unsubstantiated at this time.

On the allegation, “Staff are overmedicating resident,” the complainant was concerned that C1 was unresponsive to verbal communication and touch, and the concern was that it appeared C1 may be overmedicated. LPA interviewed the administrator and staff, made observations, and reviewed records.



On 7/13/22, the administrator and staff say C1 was not overmedicated and responds to their communication. Staff say they have not seen a change in condition and would report it to the administrator, if observed. LPA observed C1 and did not see any visible signs of unresponsiveness.

On 7/20/23, LPA reviewed C1’s Centrally Stored Medication Records (CSMR) and Medication Administration Records (MARS) for January 2021 – July 2022. Records indicate that C1 was being given the correctly prescribed medications and dosages during this period. There was no indication that C1 was being given any other medications nor being given dosages incorrectly. There were also no incident reports identifying medication errors for C1 during this time period. Based on evidence obtained, the allegation, “Staff are overmedicating resident,” is deemed Unsubstantiated at this time.

On the allegation, “Staff are not providing a comfortable environment for resident,” the complainant’s concern was that C1 was left alone in the living room with a client of the opposite sex and is concerned that something may happen. To investigate, LPA interviewed the administrator and staff and made observations.



On 7/13/22, the administrator states she has never witnessed client behaviors that could jeopardize the safety of other clients. She says there have been no incidents that would cause concern for clients to be temporarily alone with one another because staff are always with the clients. Administrator says the facility has working cameras in the common areas, if they had any concerns. Administrator says there is no verbal nor written agreement with any client’s authorized representative regarding clients not allowed to be alone with a client of the opposite sex in a common room. Staff interviewed say they have never seen any concerning behaviors among clients except for the clients occasionally trying to steal one another’s food. LPA observed cameras in the common areas: front entrance, living room, dining room, and kitchen.
Continued on 9099-C.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20220705102920
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: 08/24/2023
NARRATIVE
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On 8/24/23, LPA observed staff (3) assisting clients. When LPA inquired about a client’s whereabouts, staff immediately knew the location of each client. LPA observed clients with staff, in their individual rooms, or in the living room (2) separated and not engaging with one another. Based on the evidence obtained, the allegation, “Staff are not providing a comfortable environment for resident,” is Unsubstantiated at this time.

On the allegation, “Staff are not providing adequate food service to resident,” the complainant was concerned that C1 was not getting proper nutrition and medication. LPA interviewed the administrator, staff and clients, and toured the facility.



On 7/13/22, LPA interviewed the administrator who informs LPA that the food has been the same type and quantity offered to C1 and nothing has changed in C1’s diet. Staff interviewed say that C1 eats the same amount of food they have always eaten.

On 7/13/22, LPA looked in the refrigerators (2) and kitchen cabinets and observed a minimum 2-day supply of perishables and 7-day supply of nonperishables. The food appeared to be of good quality and a good variety of meats, vegetables, fruits, breads and beverages. LPA reviewed C1’s CSMR and MARS and found no evidence of malnutrition or medication errors.

On 8/24/23, LPA observed quantity and quality of food. There were no concerns. LPA attempted to interview clients about breakfast, and clients (5) were nonverbal. Client #2 (C2) states he had a “good” breakfast. Based on evidence obtained, the allegation, “Staff are not providing adequate food service to resident,” is deemed Unsubstantiated at this time.

On the allegation, “Resident has gained an excessive amount of weight,” the complainant’s concern was that C1 appears to have gained around 80 pounds in the past five years. LPA interviewed the administrator and staff and reviewed records.



On 7/13/22, LPA interviewed caregiving staff. Staff say they take C1 to day program and the park to go walking, approximately a half mile about three times a week. Staff say C1 has not been eating any more than usual and has not communicated that they want more food. Staff report they do not know the reason for C1’s weight gain.

Continued on 9099-C.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 29-AS-20220705102920
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: 08/24/2023
NARRATIVE
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On 7/20/23, LPA interviewed the administrator. Administrator says that in May 2021, C1’s neurologist retired without notice, and they could no longer get the prescribed Oxcarbazepine 300mg, 2x daily. She says she reached out to C1’s primary physician on 5/24/21 who prescribed Divalproex 250mg, 4x daily for C1. She says that C1 had a follow-up appointment on 6/28/21 and the medication was working well. She explains that they met again with C1’s primary physician on 9/27/21, and the administrator informed the doctor that C1 was “gaining a little weight.” She says they met on 11/8/21, and she told the doctor that C1 was “gaining a lot of weight.” On 1/24/22, the administrator informed the doctor C1 was still gaining weight and provided C1’s weight chart at which point the doctor agreed C1 had gained a lot of weight due to taking Divalproex. She says the doctor then took C1 off Divalproex and prescribed Oxcarbazepine 250mg, 4x daily. Administrator says C1’s doctor retired shortly after that appointment, and they were unable to evaluate the effect of Oxcarbazepine on C1’s weight. On 7/29/22, the administrator took C1 to a new physician who has been evaluating C1’s medications and weight history.

On 7/20/23, LPA reviewed C1’s CSMR, MARS, and Weight Record. Records coincide with the administrator’s interview in that staff were evaluating C1’s health and taking required measures to resolve the weight gain. Based on the evidence obtained, the allegation, “Resident has gained an excessive amount of weight,” is deemed Unsubstantiated at this time.

On the allegation, “Staff are not providing hygiene products for resident,” the complainant’s concern was that there was no lotion available to place on C1’s feet when requested. LPA interviewed the administrator and made observations. To investigate, LPA interviewed the administrator and staff and made observations.



On 7/13/22, the administrator states, “We keep the lotion in the locked cabinet, but we don’t put lotion on C1’s feet because C1 takes their socks and shoes off and it would be a slip hazard.” Staff interviewed confirm they also do not put lotion on C1’s feet as C1 often walks around without socks and shoes and say this would make it too slippery for C1.

On 7/13/22, LPA observed a bottle of lotion in the locked cabinet in the dining room. It appeared to be nearly full and approximately 24 ounces. The floor in all common areas is vinyl and could pose a slip hazard, if lotion were applied to client’s feet while they were walking through the facility. Based on evidence obtained, the allegation, “Staff are not providing hygiene products for resident,” is deemed Unsubstantiated at this time.

Continued on 9099-C.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 29-AS-20220705102920
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: 08/24/2023
NARRATIVE
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On the allegation, “Staff are retaliating against residents authorized representative for filing a previous complaint,” the complainant had concerns that an authorized representative was being retaliated against due to the representative taking photos in the facility in the past. The complainant explains that the representative was required to sign a document stating they were no longer allowed to take photos. LPA interviewed the administrator and staff and reviewed records.

On 7/13/22, the administrator says she and staff do not have issues with any visitors. She says that C1 has a visitor about once a year who took several photos at their previous visits and made comments that they were “checking on the place.” Administrator says she reminded C1’s visitor of the Visitor Policy which specifically states, “No photography is to take place unless verbal consent can be given explicitly.” LPA reviewed the signed copy of the Policy by C1’s visitor as well as two other clients’ visitors who signed the same Visitor Policy in 2019 and 2021. Since all visitors are required to adhere to this Policy, there is no indication that the standard is different for each visitor. Based on the evidence obtained, the allegation, “Staff are retaliating against residents authorized representative for filing a previous complaint,” is Unsubstantiated at this time.

On the allegation, “Facility picnic bench is in disrepair,” the complainant’s concern was that the facility’s picnic bench was on unstable ground with potential for clients in care to fall, if sat on the bench. To investigate, LPA toured the facility and interviewed the administrator.



On 7/13/22, LPA toured the facility with the administrator, observed the plastic/metal picnic table with benches located outside the dining room window. LPA observed the table/bench on a dirt and grass area. The ground beneath the picnic table was uneven to the extent it was on grass and dirt. LPA sat on one side of the bench, and it moved downward approximately a half an inch. The movement was not enough to cause LPA to slip or fall, and LPA was able to get up from the table/bench without difficulty. The table/bench was in good condition, no broken pieces, and fully functional. The administrator says the soil changes with the weather and the ground may have shifted, but that she has not seen a problem with the table/bench shifting enough for anyone to fall or injure themselves while sitting at the table. The backyard has an additional patio area with a covered table and chairs at the back entrance, available for client use. Based on evidence obtained, the allegation, “Facility picnic bench is in disrepair,” is deemed Unsubstantiated at this time.

Continued on 9099-C.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 29-AS-20220705102920
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: 08/24/2023
NARRATIVE
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On the allegation, “Facility yard is full of debris,” the complainant was concerned that the yard had a large amount of twigs and leaves making the ground unstable which could lead to clients tripping or falling.

On 7/13/22, LPA toured the facility. The facility has large trees in the backyard, and LPA observed the grass area sprinkled with leaves. The leaves did not appear to be in piles nor an excessive amount. LPA walked through the entire backyard and did not experience an excessive quantity of leaves and twigs nor a surface which could be potentially harmful to clients in care. On 8/24/23, LPA toured the facility and observed a neat, trim yard with no excess debris. Based on the evidence obtained, the allegation, “Facility yard is full of debris,” is deemed Unsubstantiated at this time.

Exit interview conducted, report given.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6