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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405800061
Report Date: 11/05/2024
Date Signed: 11/05/2024 10:45:29 AM

Document Has Been Signed on 11/05/2024 10:45 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 HOUSEFACILITY NUMBER:
405800061
ADMINISTRATOR/
DIRECTOR:		JONI CHAPMANFACILITY TYPE:
735
ADDRESS:13600 SAN ANTONIOTELEPHONE:
(805) 466-6274
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY: 6CENSUS: 6DATE:
11/05/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Administor, Joni ChapmanTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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 On 11/05/2024, Licensing Program Analyst (LPA) Mark Jeffries conducted a case management visit to follow up on an incident report that was self reported by the facility above. LPA met with Administrator Joni Chapman and explained the purpose of the visit.

LPA De Leon received a call from Staff 1 (S1) at the San Antonio facility reporting an incident for resident 1 (R1). R1’s middle finger was found split open by morning staff. R1 was taken to the Emergency Room (ER) to have the finger looked at. S1 stated the Managers were going to watch the surveillance video to see what happened to R1. The facility sent in a written incident to the department after watching the video and explained that on 10/27/2024 at 11:14pm Staff 2 (S2) was seen on video pushing a table into R1’s stomach area preventing R1 from entering through the doorway into the kitchen. S2 proceeded to pull up a chair at the other end of the table and continued to hold the table in place blocking the doorway so that R1 could not pass through. R1 tried moving the table side to side trying to get past the table, when S2 shoved the table into the wall catching R1’s right middle finger between the table and the wall, smashing R1’s finger and splitting it open.

S2 was seen on video putting on gloves and attempting to apply pressure to R1’s finger and cleaned up the blood. S2 failed to report incident to a supervisor in S2’s 8-hour shift.

R1 was taken to Twin Cities Hospital Emergency room (ER). The ER doctor assessed and cleaned the wound. Advised the staff that no stitches could be applied due to not seeking timely medical attention and it had been to long and the wound would not heal properly. R1 was prescribed 5 days of antibiotics.

LPA De Leon reviewed the incident report, SOC 341 Abuse Reporting form and the video surveillance recording of the incident. LPA Substantiated the finding

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

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE: DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2024
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 11/05/2024 10:45 AM - It Cannot Be Edited


Created By: Mark Jeffries On 11/05/2024 at 08:27 AM
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: 11/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/06/2024
Section Cited
CCR
80072(a)(3)

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(a)…each client shall have personal rights which include, but are not limited to, the following:(3)To be free from corporal or unusual punishment, infliction of pain… including but not limited to: interference with the daily living functions, …. This requirement was not met as evidenced by:
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Administrator agreed to conduct abuse and mandated reporting training as well as come up with a written policy on how to avoid staff abuse with CALL contacts for staff to call before a staff loses control.
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Based on record review the Licensee did not comply with the regulations above S2 caused injury to R1’s finger while blocking R1 into hallway and not allowing access to the kitchen which possess an immediate Personal Rights risk to residents 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:Mark Jeffries
LICENSING EVALUATOR SIGNATURE:
DATE: 11/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2024


LIC809 (FAS) - (06/04)
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