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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366425325
Report Date: 02/07/2025
Date Signed: 02/07/2025 04:55:21 PM

Document Has Been Signed on 02/07/2025 04:55 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 MANORFACILITY NUMBER:
366425325
ADMINISTRATOR/
DIRECTOR:		TERESA BADDELEYFACILITY TYPE:
740
ADDRESS:7421 MINSTEAD AVETELEPHONE:
(760) 552-9980
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY: 6CENSUS: 6DATE:
02/07/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:54 PM
MET WITH:Donna Norton- CaregiverTIME VISIT/
INSPECTION COMPLETED:
05:09 PM
NARRATIVE
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Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with Caregiver, Donna Norton and introduced self and stated purpose of the visit. LPA was informed that there are currently 6 residents in care who are in the facility. LPA telephone called the Licensee, Teresa Baddeley and informed her about the purpose of the visit.

The facility has 3 resident bedrooms, 1 staff bedroom, 2 bathrooms, kitchen, dining area, living room, family room, laundry room, attached garage, and backyard. LPA completed a walk through of facility, and review of records.

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 71 degrees fahrenheit. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA observed a resident occupying a staff bedroom without fire clearance approval. Deficiency issued. LPA inspected resident bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 120 degrees fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms, fire extinguisher and first aid kit. Posters such as; the ombudsman, administrator certificate and license were posted in a common area. LPA also observed cleaning supplies, toxins, sharps, and other dangerous items locked in cabinets made inaccessible to residents. There was a designated storage space for resident/staff files. Medications were observed secured and inaccessible to residents. There are no bodies of water, guns or ammunition in the facility.

Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Facility has a wide variety of food available for residents. Dishes, cups, and utensils were also stored properly.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 02/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2025
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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Document Has Been Signed on 02/07/2025 04:55 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 02/07/2025 at 04:17 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CHANTILLY LACE MANOR
FACILITY NUMBER: 366425325

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87204(a)
Limitations -Capacity and Ambulatory Status
(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by allowing a nonambulatory resident occupy a staff bedroom without fire clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/08/2025
Plan of Correction
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Licensee stated that she will move the resident to a fire clearance approved bedroom. Licensee stated that she will submit a statement of understanding to LPA via email by POC due date.
Type A
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by allowing a staff assist residens without criminal background clearance for 3 days which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/07/2025
Plan of Correction
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Licensee removed staff without criminal background clearance immediately. Licensee stated that she will submit a statement of understanding to LPA via email by 2/8/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Nedra Brown
LICENSING EVALUATOR NAME:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2025


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 02/07/2025 04:55 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 02/07/2025 at 04:17 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CHANTILLY LACE MANOR
FACILITY NUMBER: 366425325

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not having proof of a health screening and TB test for one caregiver which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/12/2025
Plan of Correction
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Licensee stated that she will send proof of the caregiver's health screening and TB test to LPA via email by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Nedra Brown
LICENSING EVALUATOR NAME:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2025


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
FACILITY NUMBER: 366425325
VISIT DATE: 02/07/2025
NARRATIVE
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Yards/Outside: One shaded patio, a side gate with self-latching handle on the right side of the house that leads into the backyard, and a attached garage used for storage. All outdoor pathways were free of obstructions.

Record Review: LPA reviewed 3 resident files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed personnel and administrator files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA observed no health screening and TB for 1 caregiver. Deficiency issued. LPA observed a second caregiver arrive and assist residents without background clearance. LPA interviewed caregiver and stated that they had already worked 3 days prior. Deficiency with civil penalty issued. LPA reviewed the facility's insurance coverage, emergency disaster plan, infection control plan and emergency drills. LPA observed that the Infection Control Plan was not reviewed/updated annually. Technical violation issued. LPA observed that the Emergency Disaster Plan was not reviewed/updated annually. Technical violation issued.

Deficiencies, two technical violations and one civil penalty were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC9102TV, LIC421BG and appeal rights were discussed and copies were provided to Caregiver, Donna Norton.

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

DATE: 02/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2025
LIC809 (FAS) - (06/04)
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