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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405800061
Report Date: 02/17/2022
Date Signed: 02/17/2022 03:35:30 PM

Document Has Been Signed on 02/17/2022 03:35 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:JONI CHAPMANFACILITY TYPE:
735
ADDRESS:13600 SAN ANTONIOTELEPHONE:
(805) 466-6274
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY: 6CENSUS: 6DATE:
02/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Joni Chapman, AdministratorTIME COMPLETED:
12:20 PM
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At 10:45 am, on 2/17/2022, Licensing Program Analyst (LPA) Darlene Chavez conducted an unannounced annual infection control inspection of the facility above. LPA met with Joni Chapman, Administrator, and explained the reason for the visit. LPA and administrator toured the facility.

LPAs’ initial tour of the facility resulted in the following observations: LPA was screened upon entry to the facility by staff. LPA observed the fire extinguisher in the hall near administrator’s office was last inspected in November 2020 and the fire extinguisher on the kitchen counter did not have an inspection date. Administrator will get the fire extinguishers up to code and send photos to LPA. LPA did not observe Provider Information Notices (PINs) nor PIN summaries posted in the facility. Administrator will print PINs and/or PIN Summaries and place in a binder and place in a common area or post on a wall/board in a common area.

At 11:15 am, LPA Chavez conducted the Infection Control mitigation module with the administrator. No deficiencies noted.

Exit interview conducted and the report emailed to the administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE: DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/17/2022
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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