405800061-2-26-2026-29-AS-RDLN-DRP24U-20260226160432

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405800061
Report Date: 02/26/2026
Date Signed: 02/26/2026 04:05:07 PM

Document Has Been Signed on 02/26/2026 04:05 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 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: 3	DATE:	02/26/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:13 PM
MET WITH:	Joni Chapman		TIME VISIT/ INSPECTION COMPLETED:	04:15 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 arrived at 1:13pm to conducted a 1 year annual visit to the facility above. LPA met with Administrator Joni Chapman and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit: Infection Control: The facility has submitted a current Infection Control Plan to the department. The bathrooms have toilet paper, paper towels, and hand soap. The facility has EPA approved disinfectants spray and cleaners. The facility has a 30 day supply of PPE. Quarantined or isolated individuals will have meals and medication delivered to rooms. Staff will be trained on infection control and the use of Personal Protective Equipment (PPE) initially upon hire and annual thereafter. Physical Plant & Environmental Safety: The facility is a 5 bedroom and 3 bathroom currently occupying 3 residents and employs 11 staff, and 1 Administrator. The facility is clean, safe and sanitary. LPA was authorized to enter and inspect facility. The facility has smoke alarms and a carbon monoxide detector. The lighting and lamps are sufficient for the use of the facility and for residents comfort. The showers have non-skid bottoms or mats present. Toilet, hand washing and bathing facilities are operational. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant, cleaning solutions and poisons are inaccessible to residents in care locked in laundry room cupboards, and storage closet. The facility has sufficient space inside and outside for activities and visiting. The facility has a backyard for client use with plenty of shade. The facility has telephone and internet service for resident use. Water temperatures were checked at bathroom sink and measured 115.1 F, within regulation requirements. Continued 809-C

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Rachael De Leon
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/26/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2026

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: 02/26/2026

NARRATIVE

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Operational Requirements: The facility has a current plan of operation on file with the department. The Facility is operating in compliance with the granted fire clearance. The facility has exiting door alarms, video surveillance and self closing, self latching gate with fencing all the way around the front and back yard. The facility is approved for a capacity of 6 Ambulatory.
Staffing: Staff have confidential files, 5 files were reviewed for finger print clearances, health screening with TB results, Personnel records or applications, Criminal record statements, and 1st Aid & CPR certificates. The administrator file had continuing education and administrator certificate expires 01/2027
Personnel Records & Training: Personnel Records were present and kept confidential The facility provides Relias 40 hour Initial and 20 hour Continued training of staff at the facility on Disaster & Quarterly Drills, Nutrition, Safety, First Aid, CPR, CPI, Driver Class & Test, Medications, Clients Rights & Mandatory Reporting, Water Safety, and Harassment Prevention as well as training on the Emergency Evacuation Plan, PPE and Infection Control. 5 staff files reviewed met the required initial and annual training.
Clients Rights: The facility conducts annual training on clients rights. Personal rights for ARF facilities is posted in the common area of the facility as well as rights with persons with disabilities.
Clients Records & Incident Reports: The facility keeps resident records confidential. LPA reviewed 3 Resident files for Signed Admission Agreements, Medical Assessments with TB results, Consent Forms, ID and Emergency Information sheet, Safeguard for Personal Property, Appraisal Needs and Services Plans are completed as Individual Service Plans with Tri-Counties Regional Center (TCRC), Personal Rights, and Safeguard for Cash Resources all forms were up to date and legible. LPA audited 3 residents P&I Money with ledger, cash and receipts which all balanced.
Food Service: The facility handles and prepares food safely. The facility has 2 day perishables and 7 day non-perishables to meet the food service requirement. The freezer is kept at 0 degrees and the refrigeration is kept at 45 degrees or lower. All food is covered, stored and marked appropriately. Food, snacks and drinks are available when the residents want them. Emergency supply of food and water is available. A menu is posted for residents in care. Cleaning solutions and equipment are stored separately than food supply. Kitchen areas are kept clean and free from litter, rodents, vermin and insects. Kitchen staff are observed for personal hygiene and food sanitation practices.
Continued 809-C

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Rachael De Leon
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/26/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2026

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: 02/26/2026

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Health Related Services: The facility makes appointments for the residents for medical and dental care. LPA conducted an audit of 3 residents medications, all medications were stored in original containers, No medication was expired, and no medication labels were altered. The facility handles PRN medications and works with the residents physician if needed. Staff assist residents with self administration of medications.
Incidental Medical Services: The facility provides transportation or assist in providing transportation to medical and dental appointments. The facility does not currently have any residents with restricted or prohibited health conditions. The facility will work with all Home Health Agencies to provide residents care and assistance when ordered by a doctor for those services.
Disaster Preparedness: The facility has a current Emergency& Disaster Plan. The staff are trained on the plan annual and the plan is reviewed and updated if needed on an annual basis. The facility has a plan if needed to be self reliant for 72 hours. The facility has emergency food and water supply, as well as flash lights with batteries. The facility has 3 relocation, 1 location is out of immediate area, if evacuation is needed. The facility has a current floor plan with emergency evacuation locations. The facility keys are available to all staff on all shifts in case of an emergency. The residents all have emergency packets ready and available when and if needed all required information is present. Facility conducts disaster drills quarterly to prepare for several different emergency scenarios.
Emergency Intervention: The facility does not use restraints or seclusion on residents in care. Staff are required to take CPI training.
LPA interviewed 3 staff and residents were out at day program or out in the community.

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: 02/26/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2026

LIC809 (FAS) - (06/04)

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