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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800121
Report Date: 02/07/2024
Date Signed: 02/07/2024 03:05:23 PM

Document Has Been Signed on 02/07/2024 03:05 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
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: 6DATE:
02/07/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Stephanie Smith- CaregiverTIME COMPLETED:
03:12 PM
NARRATIVE
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Licensing Program Analyst (LPA) Michelle Echeverria arrived at the facility unannounced on 2/7/24 and was granted entry by caregiver, Stephanie Smith. LPA explained the purpose of today's visit to Smith. The purpose of today's visit was to follow-up on Plan of Correction (POC) previously due on 02/02/2024 for deficiencies cited on form LIC9099-D issued on 01/24/2024. Smith then phoned the administrator, Teresa Baddeley to notify her about the visit.

The following deficiency was not corrected by the POC due date nor at the time of this visit. Civil penalties are being assessed and will continue to accrue until correction has been submitted:
  • Deficiency cited under Title 22 Regulation 87465(b) and POC was for Licensee to hold a training with staff and submit proof to LPA via email by 02/02/24. Proof of training was not received. LPA spoke to the administrator over the phone and stated that she did not submit a POC since she was appealing the deficiency cited.

Civil penalties assessed today at the rate of $100 per day per citation per violation per day until the violation is corrected.

Exit interview conducted with and a copy of this report, LIC421FC, and appeal rights were provided to Stephanie Smith.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 02/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2024
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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