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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405800061
Report Date: 01/04/2024
Date Signed: 01/04/2024 01:27:27 PM

Document Has Been Signed on 01/04/2024 01:27 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:
01/04/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Joni Chapman, AdministratorTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) De Leon conducted a Case Management - Incident to the facility above. LPA met with Administrator Joni Chapman and explained the purpose of the visit.

LPA De Leon received a self reported incident report from the facility regarding a resident. LPA De Leon received a copy of video footage showing an incident occurring between staff 1 (S1) and resident 1 (R1) at the facility. The video footage did not have sound. The footage showed S1 using a chair prodding at R1 to keep R1 from coming into the kitchen and getting in the drawer, the staff was grabbing at or near R1 and R1 was being pulled across the floor. The video did not show all the angles of the footage. The facility has video footage in the common areas of the home and due to a staff not clocking out on a shift the Fiance Manager watched video footage on 12/20/2023 to verify the time the staff left the facility for payroll hours worked purposes. The Finance Manager immediately notified the Executive Director of C.A.L.L the video footage showed an incident with S1 and R1. S1 was immediately put on suspension on 12/20/2023 and S1 was terminated by the facility on 12/21/2023. R1 did not have any noticeable injuries from the incident.

LPA requested the following records from the facility: R1's LIC. 602 Physicians Report, Appraisal needs and services plan, TCRC's IPP /or ISP, Staff notes and/or charting for R1 from 12/01/2023-12/31/2023, S1 personnel file with a copy of any and all disciplinary records for any facility S1 worked at during S1's employment with the C.A.L.L. programs and facilities, The name of the staff that came on shift on 12/04/2023 at 7:00am and the name of the staff that comes on shift and is shown in the video footage.

Exit interview conducted, deficiency cited, copy of report and appeal rights printed for Administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE: DATE: 01/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/04/2024
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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Document Has Been Signed on 01/04/2024 01:27 PM - It Cannot Be Edited


Created By: Rachael De Leon On 01/04/2024 at 12:56 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: 01/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/05/2024
Section Cited
CCR
80072(a)(3)

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(a)...:(3)To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to:...This requirement was not met as evidenced by:
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Administrator agreed to provide trianing to all staff at the facility on regulations 80072 and 85072, as well as abuse reporting and mandated reporter trianing. Provide trianing records as well as staff signatures for all staff taking the trianing and an up to date LIC 500 with current staff working at the facility.
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Based on video footage the liensee did not comply with the regulation above, S1 was shown to be using unusual punishment to R1 in the video footage which poses an immediate health, safety and personal rights risk to resident in care.
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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:Rachael De Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 01/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/04/2024


LIC809 (FAS) - (06/04)
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