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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426709
Report Date: 02/27/2026
Date Signed: 02/27/2026 02:17:03 PM

Document Has Been Signed on 02/27/2026 02:17 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 MANOR IIFACILITY NUMBER:
366426709
ADMINISTRATOR/
DIRECTOR:		BADDELEY, TERESAFACILITY TYPE:
740
ADDRESS:8430 "I" AVENUETELEPHONE:
(760) 956-5375
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY: 6CENSUS: 4DATE:
02/27/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:05 AM
MET WITH:Teresa BaddeleyTIME VISIT/
INSPECTION COMPLETED:
02:25 PM
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 were granted entry to the facility and met with Licensee Teresa Baddeley. At the time of the visit there was one (1) staff, The Licensee, and three (3) residents present.

Physical Plant: Indoor and outdoor passageways are free of obstructions. The facility is maintained at a comfortable temperature of 70 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 105 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 Community Care Licensing complaint poster, 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 II
FACILITY NUMBER: 366426709
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 were complete. LPAs reviewed three (3) residents medications. LPAs found that R1 and R2 medication records were not accurately maintained by staff. Deficiency issued.

LPAs reviewed three (3) staff files for First Aid/CPR certifications, criminal record clearances, trainings, and health screenings. LPAs observed staff#1 (S1) and staff#3 (S3) did not have a health screening with tuberculosis results on file. Staff#2 (S2) did not have a health screening on file. S3 did not have First Aid/CPR certification on file. Deficiency issued.

Based on the observations made during today’s visit, deficiencies were cited per Title 22, Division 6, of the California Code of Regulations and per Health and Safety Codes (HSC)

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

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)
Page: 3 of 6
Document Has Been Signed on 02/27/2026 02:17 PM - It Cannot Be Edited


Created By: Magda Malcore On 02/27/2026 at 01:39 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 II
FACILITY NUMBER: 366426709

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observations, the licensee did not comply with the section cited above by staff#1(S1) and staff#3 (S3) did not have a health screening with tuberculosis results on file. Staff#2 (S2) did not have a health screening on file; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/13/2026
Plan of Correction
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The Licensee shall provided documentation of health screening with tuberculosis results for S1 and S3. The licensee shall provide documentation of health screening for S2 to the licensing agency.

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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Document Has Been Signed on 02/27/2026 02:17 PM - It Cannot Be Edited


Created By: Magda Malcore On 02/27/2026 at 01:39 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 II
FACILITY NUMBER: 366426709

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observations, the licensee did not comply with the section cited above by staff #3 (S3) did not have a First Aid/CPR certification on file; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/13/2026
Plan of Correction
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The Licensee shall provide documentation of first aid/CPR certification/training to the licensing agency.
Type B
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observations the licensee did not comply with the section cited above by Resident #1 (R1) and Resident #2 (R2) medication records were not accurately maintained by staff when compared to medication given; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/13/2026
Plan of Correction
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The Licensee shall retrained staff on medication management training. Training documentation shall include the name of the trainer, names of staff with signatures, attending the training.
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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Document Has Been Signed on 02/27/2026 02:17 PM - It Cannot Be Edited


Created By: Magda Malcore On 02/27/2026 at 01:39 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 II
FACILITY NUMBER: 366426709

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
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Based on LPAs observations, the licensee did not comply with the section cited above by the facility does not have enough emergency food and water for 72 hour emergency. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/13/2026
Plan of Correction
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Licensee shall submit proof of purchase or pictures of the items for the 72-hour emergency food and water.
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.
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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