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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366425325
Report Date: 10/19/2022
Date Signed: 10/19/2022 12:27:57 PM

Document Has Been Signed on 10/19/2022 12:27 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:CHANTILLY LACE MANORFACILITY NUMBER:
366425325
ADMINISTRATOR:TERESA BADDELEYFACILITY TYPE:
740
ADDRESS:7421 MINSTEAD AVETELEPHONE:
(760) 552-9980
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY: 6CENSUS: 5DATE:
10/19/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:52 AM
MET WITH:Teresa Baddeley, LicenseeTIME COMPLETED:
12:40 PM
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Licensing Program Analysts (LPA’s) Rayshaun Nickolas and Amber Coleman made an unannounced visit to the facility to conduct a Health and Safety case management visit. This case management visit is in response to a special incident report (SIR) that was received by this agency from the facility on October 18, 2022. LPAs met with Licensee Teresa Baddeley and explained the purpose of the visit.

The SIR documents on October 15, 2022 and October 16, 2022, staff # 1 (S1) was sleeping on the couch all night and neglected patients all night. The Licensee terminated the staff after reviewing the facility cameras.

Inquiry into this incident included conducting a tour of the facility to assess for any Health and Safety concerns. LPA's interviewed the Licensee and clients.

There are no health and safety concerns observed during this visit.

No deficiencies were cited during this visit. An exit interview was conducted where this report (LIC 809) was discussed and provided to the Licensee.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2022
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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