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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800121
Report Date: 01/31/2023
Date Signed: 01/31/2023 10:29:42 AM

Document Has Been Signed on 01/31/2023 10:29 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:CHANTILLY LACE MANOR IVFACILITY NUMBER:
361800121
ADMINISTRATOR:BADDELEY, TERESAFACILITY TYPE:
740
ADDRESS:13365 HIDDEN VALLEY RDTELEPHONE:
(760) 241-0991
CITY:VICTORVILLESTATE: CAZIP CODE:
92395
CAPACITY: 6CENSUS: 4DATE:
01/31/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Administrator Teresa BaddeleyTIME COMPLETED:
10:40 AM
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Licensing Program Analyst (LPA) Victoria Chitgian made an unannounced visit to the facility. The purpose of the visit was to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic. LPA was greeted by Administrator Teresa Baddeley. At the time of the visit there was two (2) staff, and four (4) residents present.

LPA discussed best practices for infection control and prevention and toured the facility inside and outside. The facility has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolating residents and caring for residents with COVID-19 positive results and/or exposures. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases, suspected cases, ensuring Personal Protective Equipment(PPE) supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the proper use and disposal of PPE.

The entrance of the facility has a check in process for staff and visitors that includes a temperature and symptom check. The bathrooms were stocked with hand soap and paper towels. Postings are seen in the bathrooms for proper hand washing procedure, and proper postings posted throughout. LPA requested to inspect the facility's PPE supplies, which were in the garage. The facility has a full thirty (30) day supply of PPE items including gloves, gowns, disinfectant, surgical masks, N95 masks, and hand sanitizer available.

All staff and residents are practicing all other COVID-19 precautions, which minimize the risk of them contracting COVID-19. LPA toured the facilities interior and exterior and there were no health and safety concerns. Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809) was discussed and provided to Administrator Teresa Baddeley.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Victoria Chitgian
LICENSING EVALUATOR SIGNATURE: DATE: 01/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/31/2023
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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