366425325-2-27-2026-56-AS-MMAE-DRPQ5F-20260227105151

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366425325
Report Date: 02/27/2026
Date Signed: 02/27/2026 10:52:07 AM

Document Has Been Signed on 02/27/2026 10:52 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		FACILITY NUMBER:	366425325
ADMINISTRATOR/ DIRECTOR:	TERESA BADDELEY		FACILITY TYPE:	740
ADDRESS:	7421 MINSTEAD AVE		TELEPHONE:	(760) 552-9980
CITY:	HESPERIA	STATE: CA	ZIP CODE:	92345
CAPACITY: 6		CENSUS: 6	DATE:	02/27/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:20 AM
MET WITH:	Donna Norton		TIME VISIT/ INSPECTION COMPLETED:	11:00 AM

NARRATIVE

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Licensing Program Analysts (LPAs) Magda Malcore and Eldin Serrano made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPAs met with Caregiver, Donna Norton and were granted entry to the facility. At the time of the visit there was one (1) staff, and five (5) residents present.

Physical Plant: Indoor and outdoor passageways are free of obstructions. The facility is maintained at a comfortable temperature of 72 degrees Fahrenheit. LPAs inspected resident bedrooms; they are equipped with the required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPAs observed sufficient furniture and lighting throughout the facility. LPAs measured and observed the water temperatures in the bathroom to be at 112 degrees Fahrenheit. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Fire extinguisher was also observed at the facility. Posters such as Ombudsman poster, labor law, facility license, and facility sketch were posted in a common area. Cleaning supplies, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for resident/staff files. There is a medication room with the resident’s medications locked. LPAs observed first aid kit and manual.

Yards/Outside: One shaded patio, one self-latching gate and an attached two (2) car garage was observed.

Food Service: Seven (7) days’ supply of Non-perishable foods and two (2) days’ supply of perishable food supply were observed and sufficient for the number of residents in care. LPAs observed that the facility does not have enough emergency food and water for 72 hour emergency. Citation issued.

NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Magda Malcore
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/27/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 02/27/2026

NARRATIVE

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Record Review: LPAs reviewed three (3) resident files for admission agreements, updated physician reports, pre-placement appraisals and needs and services plans. LPAs observed resident files reviewed were complete. LPAs reviewed three (3) staff files for First Aid/CPR certifications, criminal record clearances, trainings, and health screenings.

Based on the observations made during today’s visit, a deficiency was cited per Title 22, Division 6, of the California Code of Regulations and Health and Safety Code (HSC).

An exit interview was conducted, and this report LIC809, LIC809C, LIC809D forms, and Appeal Rights were discussed and provided to Caregiver Norton.

NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Magda Malcore
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/27/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/27/2026 10:52 AM - It Cannot Be Edited

Created By: Magda Malcore On 02/27/2026 at 10:34 AM

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: 02/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(a)(2)

Other Provisions

(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by not ensuring that the facility has the 72 hour emergency food and water included in the emergency bin which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/06/2026
	Plan of Correction
1 2 3 4	Licensee shall submit proof of purchase or pictures of the items for the 72-hour emergency food and water.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:

	Magda Malcore
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/27/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2026

LIC809 (FAS) - (06/04)

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