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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405800061
Report Date: 09/10/2025
Date Signed: 09/10/2025 11:49:39 AM

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
08/21/2025 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20250821102711
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:
09/10/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Joni Chapman, AdministratorTIME COMPLETED:
11:55 AM
ALLEGATION(S):
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Staff treat resident in an abusive manner.
Staff had inappropriate interaction with resident.
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 allegations. LPA met with Joni Chapman and explained the purpose of the visit.

LPA De Leon conducted a 10-day complaint visit on 08/25/2025 to the facility, interviewed staff, requested records and a copy of the video surveillance for 08/12/2025, records provided, and video surveillance would be watched, copied and sent to LPA. LPA received a copy of video surveillance records on 08/25/2025. LPA De Leon conducted staff interviews on 09/08/2025 at 2:43pm, 3:04pm, 4:18pm, and 4:40pm.

On the allegation: Staff treat resident in an abusive manner. LPA De Leon interviewed staff which revealed Staff 1 (S1) could lose S1’s cool, get frustrated and vent to other staff, and grab resident 1 (R1) to re-direct R1.
Continuned 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2025
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-20250821102711
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: 09/10/2025
NARRATIVE
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 LPA De Leon watched video surveillance of an incident between Staff 1 (S1) and Resident 1 (R1) on 08/12/2025 which showed S1 grab the chair R1 was sitting in at the kitchen table, turn it around in an unsafe manner and tilt it forward to get R1 to get up out of chair, R1 was a bit unstable S1 grabbed towards R1 once R1 was stable at the table R1 grabbed more food off of R1’s plate. S1 grabbed R1’s arm and shoved R1 towards the doorway leading to the front door, R1 was still chewing R1`s food as R1 was going out the front door of the facility. LPA reviewed S1’s disciplinary file and R1 had been put on administrative leave on 07/21/2025 accused of pushing of a resident in care, Community Care Licensing conducted and cited on a case management visit for S1 pushing R1 on 07/31/2025. S1 returned to work on 08/02/2025 and worked up till 08/12/2025 when this complaint was filed and S1 was terminated from employment with the company on 08/15/2025 for violating a clients rights. Based on the evidence this allegation is deemed Substantiated at this time.

On the allegation: Staff had inappropriate interaction with resident. LPA De Leon watched video surveillance of an incident between Staff 1 (S1) and Resident 1 (R1) on 08/12/2025 which showed S1 grab the chair R1 was sitting in at the kitchen table, turn chair around in an unsafe manner and then tilted it forward to get R1 to get up out of chair, R1 was a bit unstable at first and S1 grabbed towards R1, once R1 was stable at the table R1 grabbed more food off of R1’s plate. S1 grabbed R1’s arm and shoved R1 towards the doorway leading to the front door, R1 was still chewing R1`s food as R1 was going out the front door of the facility. R1 has a 1 on 1 care and no staff was with R1 out on the front patio even with R1 still chewing food as R1 was walking out the front door. S1 took R1’s plate and cup to the kitchen sink. Staff interviews revealed R1 does take longer to eat as R1’s food must be chopped up and R1 is not able to always pick up smaller pieces with R1’s hands which causes R1 to take a little longer eating. Witness 1 (W1) interview revealed it was told to W1 that S1 belittled R1 after having an accident and shoved R1 into the shower. Based on the evidence this allegation is deemed Substantiated at this time.

The Administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1548((f)(1)(A).

Exit interview conducted, deficiencies cited, civil penalty assessed, copy of report and appeal right printed for Administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20250821102711
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: 09/10/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/11/2025
Section Cited
CCR
80072(a)(3)
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(a)...(3)To be free from... unusual punishment,... humiliation, intimidation, ridicule,..., or other actions of a punitive nature, including but not limited to: interference with the daily living functions, including eating,... toileting;... This requirement was not met as evidence by:
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The administrator agreed to have all staff watch the videos of incidents on 07/20/2025 and 08/12/2025, in-person with training to show all the staff what parts were not acceptale, what was acceptable and what each staff could have done differently, see below:
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Based on interviews and video surveillance, the Licensee did not comply with the regulation above S1 did not allow R1’s to finish R1's food and agressively pushed R1 out the doorway while still chewing which poses an immediate health, safety and personal rights risk to residents in care.
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review mandated reporting, review R1’s Behavior/IPP plans and 1 on 1 care. Provide proof of training with an up-to-date LIC. 500.
Type A
09/11/2025
Section Cited
CCR
80072(a)(1)
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(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:(1)To be accorded dignity in his/her personal relationships with staff and other persons. This requirement was not met as evidenced by:
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Administrator agreed to hold training for all staff on client’s rights for adult facilities and rights of people with disabilities. provide proof of trianing with LIC 500.
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Based on video surveillance and interviews the Licensee did not comply with the regulation above S1 put hands on R1 by pushing R1 away from R1 foods and not allowing R1 diginity in the interactions with S1 which posses an immdeiate health, saefty and 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.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3