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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800121
Report Date: 11/15/2024
Date Signed: 11/15/2024 10:47:45 AM

Document Has Been Signed on 11/15/2024 10:47 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/
DIRECTOR:		BADDELEY, TERESAFACILITY TYPE:
740
ADDRESS:13365 HIDDEN VALLEY RDTELEPHONE:
(760) 241-0991
CITY:VICTORVILLESTATE: CAZIP CODE:
92395
CAPACITY: 6CENSUS: 6DATE:
11/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:25 AM
MET WITH:Stephanie Smith-CaregiverTIME VISIT/
INSPECTION COMPLETED:
11:05 AM
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Licensing Program Analyst (LPA) Michelle Echeverria made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Caregiver, Stephanie Smith and was granted entry to the facility. LPA was accompanied by Stephanie to conduct a general overall inspection, which included, but was not limited to, the following:

The facility has 4 bedrooms, 3 bathrooms, kitchen, dining area, living room, entry room, laundry room, garage and backyard. LPA completed a walk through of facility, review of records and medication audit.

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 74 degrees fahrenheit. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected resident bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 119 degrees fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms, charged fire extinguisher, and first aid kit. Posters such as; the personal rights, CCL complaint poster, ombudsman, and license were posted in a common area. Cleaning supplies, toxins, sharps, medications and other dangerous items were kept in secure cabinets inaccessible to residents. Residents/Staff files were observed locked and made inaccessible. There are no bodies of water, firearms or ammunition in the facility. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care.

Food Service: LPA observed 2 days of perishables and 7 days non-perishables food, pantry stocked and up to date. Facility has a variety of food available. Dishes, cups, and utensils were stored properly.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 IV
FACILITY NUMBER: 361800121
VISIT DATE: 11/15/2024
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Yards/Outside: One shaded patio, a side gate with entrance/exit to the facility on the left and right side. All outdoor pathways were free of obstructions.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Record Review: LPA reviewed resident files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. Medication was audited and matched with record. LPA reviewedemergency disaster plan and disaster drills. LPA observed that the facility did not have a copy of the report sent to the local fire jurisdiction about oxygen used in the facility. Technical violation issued. LPA observed that the bedrooms with oxygen did not have oxygen in use signs. Technical violation issued.

No deficiencies and two technical violations were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, and LIC9102TV were discussed and copies were provided to caregiver, Stephanie Smith.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024
LIC809 (FAS) - (06/04)
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