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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405800061
Report Date: 01/29/2025
Date Signed: 01/29/2025 04:00:39 PM

Document Has Been Signed on 01/29/2025 04:00 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/
DIRECTOR:		JONI CHAPMANFACILITY TYPE:
735
ADDRESS:13600 SAN ANTONIOTELEPHONE:
(805) 466-6274
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY: 6CENSUS: 5DATE:
01/29/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:40 PM
MET WITH:Joni Chapman, Administrator TIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) De Leon conducted a subsequent case management visit to deliver final findings on this investigation. LPA met with Joni Chapman, Administrator and explained the purpose of the visit.
On 10/14/2024, the Woodland Hills North Adult and Senior Care Regional Office (RO) received a self- reported incident report (SIR) from the facility regarding Staff #1 (S1) physically abusing Client #1 (C1) while in care. The case was assigned to Investigator Romelia Munoz to investigate the allegation of physical abuse.

On 10/17/2024, from 11:57am to 2:38pm, Licensing Program Analyst (LPA) Mark Jeffries conducted an unannounced case management visit based on the SIR. The incident took place on 10/13/2024 at approximately 6:00pm. The SIR summarized that Client #1 (C1) sustained a serious injury, due to suspected abuse by Staff #1 (S1). LPA Jeffries conducted an interview with the Administrator Joni Chapman, observed and recorded the video of the 10/13/2024 incident, and requested documents pertinent to the investigation. The Administrator stated that S1 was put on suspension and notified of termination on 10/15/2024. During the visit, the Administrator completed the “Suspected Dependent Adult/Elder Abuse Report” (SOC341 form) and notified local law enforcement of the suspected abuse of C1 by S1.

On 10/24/2024, from approximately 11:45am to 1:45pm, Investigator (Inv.) Munoz conducted an interview with the Administrator, and attempted to interview two other clients, who were unable to comprehend or answer questions; all other clients were noted to be non-verbal, and investigator was unable to conduct interviews. Inv. Munoz also conducted the following interviews: on 11/14/2024 at approximately 3:30pm San Luis Obispo (SLO) County Sheriff’s office detective; on 11/26/2024, at approximately 2:00pm, attempted an interview with S1 and left message; on 12/03/2024, sent S1 a letter via certified mail requesting a contact (numerous attempts were made to contact S1, however, S1 did not contact the investigator); and on 12/05/2024, at approximately 12:16pm, with another facility staff.
Continued 809-C
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2025
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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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: 01/29/2025
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 In addition, Investigator Munoz reviewed SLO County Sheriff’s Office Report #2410-07788, Twin Cities Community Hospital medical records, facility surveillance footage, and facility file documents pertinent to the investigation.

According to the facility Client Demographic Sheet, C1’s primary diagnosis was listed as mental retardation, autism, and non-verbal.

A review of the Twin Cities Community Hospital medical records revealed on 10/14/2024, C1 was admitted to the hospital for right lower leg swelling and bruising. C1 was found by facility staff that morning not wanting to put weight on C1’s right leg. Per facility staff, C1 is ambulatory, and it was not normal behavior for C1 to not get up for breakfast. There were no known falls or trauma noted in the records. C1 was diagnosed with a closed right fibula fracture and a closed extra-articular fracture of the distal end of the right tibia. On 10/15/2024, C1 had surgery to treat the injury and on 10/17/2024, C1 was discharged from the hospital.

The Department’s investigation revealed on 10/13/2024, at approximately 6:00pm, facility surveillance footage displayed S1 physically abuse C1 with the kitchen gate by pushing it towards C1 and pinning C1 against the wall. C1 fell to the ground and was unable to stand or walk for the rest of the evening. C1 was transported to Twin Cities Hospital, on 10/14/2024, at approximately 7:00am, where C1 was diagnosed with a closed right fibula fracture and a closed extra-articular fracture of the distal end of the right tibia. C1 is non-verbal; therefore, C1 suffered the pain of a broken leg without treatment for over 13 hours. S1 did not respond to interview requests, and S1 was terminated from working at the facility. The Department’s investigation confirmed S1 physically abused C1 while in care causing injury.

The Department’s investigation further revealed that S2 also physically abused C1. On 10/13/2024, at approximately 6:13pm, facility surveillance footage displayed S2 struck C1 with a stick (possibly a broom handle with a metal hook attached to one end) on C1’s hands, back, neck, and possibly face. S2 kicked C1 on the left shin while C1 was on the floor. S2 admitted S2 poked and prodded C1 with a stick; however, S2 did not admit to kicking C1. S2 was suspended and terminated from working at the facility. The Department’s investigation confirmed S2 physically abused C1 while in care.

Continued 809-C
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025
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: 01/29/2025
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This is an amended report.
In addition, during the Department’s investigation, it was revealed that the staff did not conduct safety checks on the clients every 30-minutes during the night shift as listed in the facility protocol.

A $1000 immediate civil penalty is assessed today based on H&S 1548 (c)(1). The Administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1548(f)(1)(A).

Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC809-D).

Exit interview conducted, deficiency cited, Civil penalty assessed appeal rights discussed, and a copy of this report issued to Administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 01/29/2025 04:00 PM - It Cannot Be Edited


Created By: Rachael De Leon On 01/29/2025 at 03:03 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: 01/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/31/2025
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,.. This requirement is not met as evidenced by:
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Licensee will have all staff attend a personal rights training by a qualified outside vendor and submit a plan how you are going to prevent staff from physically abusing clients. Submit to CCL by
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Based on interviews and video surveillance review, the licensee did not comply with the section cited above when S1 & S2 physically abused C1, which posed an immediate health and safety risk to clients in care.
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Type A
01/31/2025
Section Cited
CCR80075(a)

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(a) The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services. This requirement is not met as evidenced by:
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Licensee will submit plan how you will ensure clients receive timely medical treatment. Licensee will have all staff attend a training about how to seek timely medical attention. Submit to CCL by
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Based on interviews and video surveillance review, the licensee did not comply with the section cited above when staff did not seek timely medical attention for C1, which posed an immediate health and safety risk to clients 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: 01/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 01/29/2025 04:00 PM - It Cannot Be Edited


Created By: Rachael De Leon On 01/29/2025 at 03:12 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: 01/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/31/2025
Section Cited
CCR
80078(a)

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(a) The licensee shall provide care and supervision as necessary to meet the client's needs.
This requirement is not met as evidenced by:
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Licensee will submit plan how you will ensure staff conduct required client safety checks. Licensee will hold all staff training on client safety check protocol. Submit to CCL by
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Based on interviews, the licensee did not comply with the section cited above when staff did not conduct 30-minute safety checks per facility protocol, which posed an immediate health and safety risk to clients 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: 01/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2025


LIC809 (FAS) - (06/04)
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