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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366425325
Report Date: 05/09/2023
Date Signed: 05/09/2023 03:16:56 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/08/2023 and conducted by Evaluator Rayshaun Nickolas
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230508163519
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:
05/09/2023
ANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Teresa Baddeley, Licensee TIME COMPLETED:
03:25 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident sustained bruises while in care.
Staff hurt resident in care.
Staff did not provide proper medication assistance to resident in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Rayshaun Nickolas visited the facility unannounced to deliver the finding on the above allegations. LPA met with caregiver Jeannene Regets and explained the purpose of the visit. Licensee Teresa Baddeley was notified of this complaint and arrived at the facility approximately 10 minutes later. The investigation included a facility tour, file reviews, and interviews with relevant parties.

Allegation #1 “Resident sustained bruises while in care”. The allegation alleged that client #1 (C1) had bruises on their arm. LPA Nickolas’ interview with staff #3 (S3) revealed that C1 does not reside at this facility. S3 stated that C1 resided at another facility owned by the Licensee. LPA Nickolas' interview with the Licensee revealed that C1 has never resided at this facility. The Licensee stated that C1 resided at their other facility.

Allegation #2 “Staff hurt resident in care”. The allegation alleged that C1 told staff #2 (S2) that staff #1 (S1) "S1 is hurting me". LPA Nickolas' interview with S3 revealed that C1 does not reside at this facility. S2 stated that C1 resided at another facility owned by the Licensee.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 56-AS-20230508163519
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 MANOR
FACILITY NUMBER: 366425325
VISIT DATE: 05/09/2023
NARRATIVE
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 LPA Nickolas' interview with the Licensee revealed that C1 has never resided at this facility. The Licensee stated that C1 resided at their other facility. The Licensee stated that S1 has never worked at this facility.

Allegation #3 “Staff did not provide proper medication assistance to resident in care”. The allegation alleged that a client’s relative ordered S2 to give the client additional medication, and S2 did not comply. The allegation alleged that other facility staff members were over-medicating the same client. LPA Nickolas’ interview with S3 revealed they have never encountered S2 working at this facility. S3 stated that they have been working at this facility since March 2022. LPA Nickolas’ interview with the Licensee revealed that S2 does not work at this facility. The Licensee stated that S2 has never worked at this facility. LPA Nickolas’ file review revealed that S2 is on the shift schedule of another facility owned by the Licensee.

This agency has investigated the complaint allegations. We have found that the complaint was unfounded meaning that the allegations were false, could not have happened and/or are without a reasonable basis. We have therefore dismissed the complaint.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/08/2023 and conducted by Evaluator Rayshaun Nickolas
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230508163519

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:
05/09/2023
UNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Teresa Baddeley, Licensee TIME COMPLETED:
03:25 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not maintain resident records.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Rayshaun Nickolas visited the facility unannounced to deliver the finding on the above allegation. LPA met with caregiver Jeannene Regets and explained the purpose of the visit. Licensee was notified of this complaint and arrived at the facility approximately 10 minutes later. The investigation included a facility tour, file reviews, and interviews with relevant parties.

The allegation alleged that the facility throws away logbooks monthly or when patients die. LPA Nickolas' interview with the Licensee revealed that clients' records are maintained in their office for three (3) years. LPA Nickolas' file review revealed that the logbook at the facility goes back to March 31, 2023. LPA file review also revealed that all clients' records are current, complete, and maintained according to Title 22 of the California Code of Regulations. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 56-AS-20230508163519
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 MANOR
FACILITY NUMBER: 366425325
VISIT DATE: 05/09/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
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18
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31
32
A finding of Unsubstantiated means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted and copy of this report was provided.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4