405800061-3-19-2025-29-AS-KBUY-DF7P68-20250328110156

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405800061
Report Date: 03/19/2025
Date Signed: 03/19/2025 02:00:39 PM

Substantiated

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
12/12/2024 and conducted by Evaluator Rachael De Leon

COMPLAINT CONTROL NUMBER: 29-AS-20241212124657

FACILITY NAME:	C.A.L.L.-SAN ANTONIO HOUSE		FACILITY NUMBER:	405800061
ADMINISTRATOR:	JONI CHAPMAN		FACILITY TYPE:	735
ADDRESS:	13600 SAN ANTONIO		TELEPHONE:	(805) 466-6274
CITY:	ATASCADERO	STATE: CA	ZIP CODE:	93422
CAPACITY:	6	CENSUS: 5	DATE:	03/19/2025
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Joni Chapman, Administrator		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Facility staff neglect and/or abuse led to injuries of client
Facility staff did not provide timely medical care to client

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to deliver findings for the above allegations. LPA met with Joni Chapman, Administrator and explained the purpose of the visit.

On 12/12/2024, the Department received a complaint regarding Client #1 (C1) sustaining bruising and injuries due to staff neglect and/or abuse, and staff not providing C1 timely medical care. The complaint was referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Jorge Jauregui.

On 12/13/2024, from 9:13am to 10:10am, Licensing Program Analyst (LPA) Rachael De Leon conducted an unannounced initial complaint visit. Tri-Counties Regional Center (TCRC) Quality Assurance Specialist (QAS) Jeff Edler was also present during the visit. LPA De Leon and QAS Edler met with Joni Chapman, administrator, and explained the purpose of the visit. The LPA requested records pertinent to the investigation. Continued 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025

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-20241212124657

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: 03/19/2025

NARRATIVE

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The LPA informed the administrator that the Community Care Licensing (CCL) Investigations Branch (IB) had accepted the complaint for a full investigation and final findings would be delivered at a later date.

On 12/17/2024, at approximately 9:46am, Investigator Jauregui conducted interviews with C1’s resident representative; on 12/19/2024, from approximately 10:06am to 12:26pm, with facility care staff, administrator, and attempted interviews with clients (unable to conduct interviews with clients due to clients’ diagnosis of intellectual developmental disorder, low functioning, and/or non-verbal); on 12/27/2024, from approximately 12:19pm to 3:46pm, with facility care staff and Twin Cities Community Hospital Registered Nurse (RN); on 01/07/2025, at approximately 8:59am, with San Luis Obispo (SLO) County Sheriff’s Department Detective; and on 03/12/2025, at approximately 11:11pm, with facility care staff. In addition, Investigator Jauregui reviewed San Luis Obispo (SLO) Sheriff’s Department Report #2412-09017, Twin Cities Community Hospital medical records, photos of C1’s injuries, facility video footage, and facility file documents pertinent to the investigation.

According to the Physician’s Report dated 07/19/2023, C1’s primary diagnosis is listed as Autism. C1 ambulates without assistance, requires assistance in incidental health and medical care, and is unable to care for personal needs.

C1’s Annual Care Plan, dated 09/20/2024, reflects C1 was placed at the facility on 10/20/2021. C1 is non-verbal and uses a picture board to express needs. C1’s self-injurious behaviors (SIB), include banging head on floor, walls, and doors. C1 often stops when staff leave. If C1 continues, staff redirect C1 to C1’s room, which has padded walls and floor. (During the investigation, Investigator Jauregui observed C1’s bedroom and noted the walls were padded, however, the floor was hard vinyl and was not padded. There was a padded mat approximately 3’ by 6’ in size in front of C1’s bed). In addition, C1’s Care Plan states that the staff are instructed to help C1 communicate with the picture board instead of self-injuring. C1 experiences anxiety attacks about twice a week but keeping C1 occupied has helped reduce these. Medication changes and routine adjustments have further decreased the frequency of C1’s attacks. C1’s Behavior Plan indicates staff are to provide frequent one-on-one attention. Some of C1’s triggers are when staff attention is delayed and when C1 is not engaged in an activity. If C1 engages in SIB, staff are to ignore, but only if it is a gentle head tap. Staff are to place a pad on the floor, if necessary, prompt a break in a quiet room, monitor C1 closely, keep C1 busy, and contact 911 if necessary. Continued 9099-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 29-AS-20241212124657

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: 03/19/2025

NARRATIVE

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According to the incident report submitted by the facility, on 12/11/2024 at 6:37am, the overnight (NOC) staff called the administrator to report that C1 had a black eye. On the evening of 12/10/2024, the administrator received calls of C1 having a behavior crisis but wasn't informed of an injury at that time. The report states the first incident of head banging began at 5:30pm. The administrator recommended that staff encourage C1 to take time to calm down in C1’s room, where padding is provided for safety. C1 is also provided with a safety mat when C1 begins banging head when C1 isn't in their room. (However, based on the video footage reviewed, staff did not offer the safety mat to C1 during the behavior incident) The incident report also stated C1 was scheduled to have an annual physical on 12/11/2024 at 11:45am and would also receive care for the black eye, but after the administrator received a second call from staff around 8:30am stating that C1 had swelling on each side of the head, the administrator determined that C1 should be provided immediate medical care. Staff then transported C1 to Twin Cities Community Hospital for medical care.

According to the medical records reviewed, on 12/11/2024, at 9:15am, C1 was admitted to the Twin Cities Community Hospital for a head injury. C1 was very uncooperative during the examination and displayed behavior outbursts. On C1’s head, there was a frontal abrasion with surrounding hematoma and bitemporal swelling with areas of ecchymoses in stages of healing. C1 had bruising to right eye, which appeared old. C1’s breathing was abnormal, was persistently hypoxic, and had bacterial pneumonia. C1 was intubated, provided with antibiotics, and placed on mechanical ventilation and critical care due to a chance of imminent decompensation. A Computed Tomography (CT) exam was conducted, which did not show any evidence of intracranial hemorrhage or skull or facial fracture. On 12/20/2025, minimal secretions were observed. C1 was extubated and placed on tube feeds due to gradual improvement. On 12/26/2025, C1 was transferred to the Direct Observation Unit (DOU). On 01/25/2025, C1 was discharged home with 24-hour care in place.

A review of the facility video surveillance footage revealed on 12/10/2024, from 5:27pm to 5:41pm, C1 hit head on door frame, hit back and side of head on the floor approximately 5 times, and hit head twice on the wall. A non-bleeding bruise is seen on C1’s forehead. The video also shows Staff #1 (S1) looked at C1 a few times, yet S1 did not provide aid to C1. The video then shows C1 sat on the kitchen table bench and rolled off to the floor. C1 hit the back of their head twice on the floor, then hit the back of their head on the bench. Continued 9099-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 29-AS-20241212124657

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: 03/19/2025

NARRATIVE

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S2 looked at C1’s face with S2’s cell phone light. C1 rolled back on the floor and hit the back of their head on the floor. C1 sat up, rolled to the side, and leaned back, hitting the back and side of their head on a chair and the floor approximately eight times. S2 walked to the living room and returned to the kitchen, holding a pad, yet S2 did not place the pad underneath C1’s head. At 5:41pm, C1 rolled back to the area between the kitchen and the front door. S2 held a cell phone and the pad. S1 and S2 assisted C1 to their feet and walked C1 to C1’s room. The video shows at 5:50pm, 6:02pm and 6:09pm, staff checked on C1 in C1’s bedroom and bathroom. No staff was seen on the footage walking into C1’s room from 6:09pm until 6:46pm. The video shows at 6:47pm, S2 walked out of C1’s room with a paper towel. At 6:58pm, 7:12pm, 8:10pm, 8:23pm, 9:04pm, and 10:52pm, S1 and S2 walked into C1’s room for a few seconds and exited, walking back to the kitchen area. At 11:01pm, Staff #3 (S3) entered the facility through the kitchen side door. At 11:05pm, C1 walked out of C1’s room into the hallway. No facial bruising was observed. S3 walked from the kitchen area into the hallway and took C1 back to C1’s room. The footage did not show S3 walking into C1’s room from 11:07pm until 6:35am on 12/11/2024. At 6:35am, S3 entered C1’s bedroom and took C1 to the restroom across the hall. The footage only showed from the waist down to the foot, and no bruises were visible. At 8:29am, the video shows C1’s right eye looked black, and the left side of C1’s face was swollen. At 8:32am, C1 walked to the area between the kitchen and the front door and sat on the floor. S3 looked at C1’s face. At 8:38am, the video shows C1’s left eye looked black, and the left side of C1’s face was swollen. S3, S4, and C1, walked to the side exit door of the kitchen. C1 sat on the floor, removed C1’s hoodie and S3 touched the back of C1’s head. No bleeding or bruises were seen on the back of C1’s head. S4 assisted C1 to their feet and walked C1 out of the facility through the kitchen side door.

The review of the San Luis Obispo (SLO) Sheriff’s Department Report #2412-09017 revealed the case was closed based on their investigation that confirmed C1’s injuries were self-inflicted. C1 was not assaulted or intentionally harmed by staff. The report also concluded that the staff were neglectful in their lack of prompt medical response and proper supervision.

On the allegation: Facility staff neglect and/or abuse led to injuries of client. The Department’s investigation revealed that on 12/10/2024, C1 suffered an anxiety attack while in care at the facility. This resulted in self-inflicted injuries from C1 repeatedly striking their head against hard objects – floor, wall, door frame, chair and bench. C1’s behavioral plan specifies staff should closely monitor C1, if C1 exhibits self-injurious behaviors. Continued 9099-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 29-AS-20241212124657

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: 03/19/2025

NARRATIVE

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During the anxiety attack, staff took C1 to C1’s bedroom where for extended periods, as shown by the facility video footage, C1 was not checked by staff. C1’s bedroom walls are padded but not the floor. It is unknown if C1 continued to bang their head on the bedroom floor and hard objects as there are no cameras in the bedroom. Due to improper staff supervision and monitoring, staff did not notice C1’s facial and head injuries until the morning of 12/11/2024. Therefore, the allegation “Facility staff neglect and/or abuse led to injuries of client” is deemed Substantiated at this time.

On the allegation: Facility staff did not provide timely medical care to client. C1's behavioral plan specifies that staff should closely monitor C1 and contact 911 if C1 engages in self-inflicted injury behaviors. During an anxiety attack, C1 was seen on the facility video footage hitting their head on the floor and hard objects in the presence of staff. While staff acknowledged that if C1's anxiety attacks lasted more than 15 minutes, they would contact Emergency Medical Services (EMS), they did not provide medical care until the following morning, on 12/11/2024. Staff admitted they should have called EMS due to the number of times C1 hit head on the floor. At the Twin Cities Community Hospital, C1 was found to have low oxygen saturation, significant head trauma, facial swelling, and bruising. C1 was intubated and placed in a medically induced coma due to possible pneumonia and sepsis. Therefore, the allegation “Facility staff did not provide timely medical care to client” is deemed Substantiated at this time.

A $1000 repeat violation civil penalty is assessed today based on Health and Safety Code 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 LIC9099-D). Exit interview conducted, deficiencies cited, civil penalties 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: 03/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 29-AS-20241212124657

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/19/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/20/2025 Section Cited CCR 80078(a)	1 2 3 4 5 6 7	Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee/Administrator will read and provide a statement of understaning of regulation 80078 and train all staff working at the facility in the regulation, and in residents Behaviors, ISP/IPP/ANS and care plans and provide proof of trianing to CCL.
	8 9 10 11 12 13 14	Based on video footage and interviews, the licensee did not comply with the section cited above when staff neglected C1 while C1 was exhibiting self-injurious behaviors, which posed an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
Type A 03/20/2025 Section Cited CCR 80075(a)	1 2 3 4 5 6 7	(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:	1 2 3 4 5 6 7	Licensee/Administrator will review regulation 80075, provide a statement of understaning and how the facility will prevent the incident from reaccurence and provide trianing to all staff in regulation and provide proof of all to CCL with an up to date LIC 500.
	8 9 10 11 12 13 14	Based on video footage and interviews, the licensee did not comply with the section cited above when staff did not obtain timely medical care for C1, which posed an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025

LIC9099 (FAS) - (06/04)

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