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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405800061
Report Date: 07/31/2025
Date Signed: 07/31/2025 12:33:05 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
02/13/2025 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20250213123608
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: 5DATE:
07/31/2025
UNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Joni ChapmanTIME COMPLETED:
12:40 PM
ALLEGATION(S):
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Client in care sustained unexplained injuries while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above to deliver final findings of the complaint allegation. LPA met with Joni Chapman and explained the purpose of the visit.
LPA De Leon conducted the initial complaint visit on 02/19/2025 and collected records. LPA De Leon interviewed staff on 07/09/2025 at 1:43pm, 2:37pm, 2:41pm, 3:00pm, and 3:22pm. LPA De Leon subpoena Resident 1 (R1) Medical Records for Twin Cities Adventist Hospital. LPA De Leon received and reviewed records.

On the allegation: Client in care sustained unexplained injuries while in care. LPA interviewed 5/5 staff which revealed the communication and staff communication logs were not good at that time, staff want to leave once shift was over, outgoing staff were not providing incoming staff with updates on residents in care, incoming staff were not reading the notes in the communication logs before working with the residents, and communication has gotten better since this incident occurred. Cont. 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025
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 3
Control Number 29-AS-20250213123608
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: 07/31/2025
NARRATIVE
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Emergency Medical Services (EMS) were not able to provide a full report to the emergency room (ER) hospital staff regarding R1 having a black eye due to the facility staff having little to no information on it. 1/5 staff stated they went to the communication logs while EMS was at the residence and read them what information was available. LPA reviewed R1’s records which revealed R1 was diagnosed with the Flu on Friday February 7, 2025 and by Monday February 10th in the morning staff called 911 due to R1’s breathing and he had a black eye. R1 was admitted to the hospital from the ER and R1 stayed in the hospital from 02/10/2025-02/21/2025. During the review of the residence video surveillance R1 was shown to be in the living room on the floor and several times hit R1’s head on the floor, the video shows the staff placing pillows around R1 and later providing blankets to R1. The staff did make notes in the communication log that R1 had hit R1’s head on the floor and R1 was refusing to go to R1’s room, another note was made that R1 had a black eye, and photographs were sent to the Administrator. 5/5 staff interviewed said R1 would fight sleep often and R1 would become unstable and a fall risk due to R1 being so tired. R1 was not a head banger or have behaviors of head banging. Community Care Licensing did not get an incident report for the black eye and asked the facility about it and the facility sent over a late incident reporting the black eye and how it occurred. Due to poor communication and staff not reading the logs as soon as they come on shift the staff did not effectively communicate to the EMS the resident’s issues/needs at the time of the 911 call therefore the allegation is deemed Substantiated at this time.

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: 07/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20250213123608
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: 07/31/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/01/2025
Section Cited
CCR
80075(h)
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(h)There shall be at least one person capable of and responsible for communicating with emergency personnel in the facility at all times. The following information shall be readily available: This requirement was not met as evidenced by:
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Administrator and all staff working in the facility will do training with administrator reading each residents reports Behavior/ISP/ANS/Medical/Background and do in person training with each resident in care and hands on with shadowing showing allowable redirection and to meet care needs and train on exactly what 1 on 1
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Based on interviews and records review the Licensee did not comply with the regulation above staff were unable to communicate with EMS staff regarding the resident and the residents condition and staff were not aware of the how the black eye occurred until one staff read the communication logs notes which possess an immediate health, safety and personal rights risk to residents in care.
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 care is with the clients that have that care, also train on emergency scenarios calling 911 and having documentation ready for each resident in care. The facility will have a lead staff or Administrator at cross over shifts so staff can communicate and write notes in the communication logs before leaving or coming onto shift with residents in care. Send proof of training to CCL.
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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.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025
LIC9099 (FAS) - (06/04)
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