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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361800121
Report Date: 03/01/2022
Date Signed: 03/01/2022 02:16:03 PM

Substantiated


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
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/22/2022 and conducted by Evaluator Rohit Lama
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220222130445
FACILITY NAME:CHANTILLY LACE MANOR IVFACILITY NUMBER:
361800121
ADMINISTRATOR:BADDELEY, TERESAFACILITY TYPE:
740
ADDRESS:13365 HIDDEN VALLEY RDTELEPHONE:
(760) 241-0991
CITY:VICTORVILLESTATE: CAZIP CODE:
92395
CAPACITY:6CENSUS: 5DATE:
03/01/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:House Manager, YasminTIME COMPLETED:
02:20 PM
ALLEGATION(S):
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Facility did not provide resident with an appropriate sleeping arrangement.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rohit Lama made an unannounced visit to the facility to investigate the above allegation. LPA met with Caregiver Yasmin Aguirre and spoke with Administrator Teresa Baddeley over the phone.

LPA toured the facility, conducted interviews, and reviewed facility files. The allegation states that the facility did not provide adequate sleeping arrangements for Resident #1 (R1). LPA was unable to interview R1 because he had passed away prior to LPA conducting this investigation. Interviews with the Staff #1 (S1) showed that an agreement was made to have R1 move in on 2/11/2022. S1 also stated that R1 was to reside in the bedroom that was currently being occupied by another resident, Resident #2 (R2). As of 2/11/2022, R2 had not moved out. Because of this, a bedroom was unavailable for R1 and thus had to sleep in the living room.

***CONTINUED ON LIC 9099-C***
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Rohit Lama
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2022
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 5
Control Number 18-AS-20220222130445
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
RIVERSIDE, CA 92507
FACILITY NAME: CHANTILLY LACE MANOR IV
FACILITY NUMBER: 361800121
VISIT DATE: 03/01/2022
NARRATIVE
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***CONTINUED FROM LIC 9099***

Based on LPA interviews conducted and a review of records, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. California Code of Regulations (Title 22, Division & Chapter number 87307 are being cited on the attached LIC 9099D.

An exit interview was conducted, and a copy of this report was reviewed, and appeal rights were provided to Caregiver Yasmin Aguirre, whose signature on this form confirms receipt of the above-mentioned documents.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Rohit Lama
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/22/2022 and conducted by Evaluator Rohit Lama
COMPLAINT CONTROL NUMBER: 18-AS-20220222130445

FACILITY NAME:CHANTILLY LACE MANOR IVFACILITY NUMBER:
361800121
ADMINISTRATOR:BADDELEY, TERESAFACILITY TYPE:
740
ADDRESS:13365 HIDDEN VALLEY RDTELEPHONE:
(760) 241-0991
CITY:VICTORVILLESTATE: CAZIP CODE:
92395
CAPACITY:6CENSUS: 5DATE:
03/01/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:House Manager, YasminTIME COMPLETED:
02:20 PM
ALLEGATION(S):
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9
Facility staff are not adequately trained.
Facility staff did not adequately supervise residents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rohit Lama made an unannounced visit to the facility to investigate the above allegation. LPA met with Caregiver Yasmin Aguirre and spoke with Administrator Teresa Baddeley over the phone.

LPA conducted interviews, and reviewed facility files. The first allegation states that facility staff are not adequately trainined. LPA reviewed personnel files for the employees at this facility. The training logs for all Caregiovers shows that the last training session was had on 06/2021. This shows that the facility staff is being properly trained

***CONTINUED ON LIC 9099-C***
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Rohit Lama
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2022
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 5
Control Number 18-AS-20220222130445
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
RIVERSIDE, CA 92507
FACILITY NAME: CHANTILLY LACE MANOR IV
FACILITY NUMBER: 361800121
VISIT DATE: 03/01/2022
NARRATIVE
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***CONTINUED FROM LIC 9099-A***

The second allegation alleges states that facility staff did not adequately supervise residents. LPA made observations, conducted interviews, and toured the facility. LPA interviewed Residents #3, #4, and #5. All three residents stated that they believe that the facility staff is well trainined and able to provide adequate supervision to the residents at the facility. LPA also interviewed Staff #2. S2 stated that he/she has never had issues providing supervision for the residents.

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, therefore the allegation is Unsubstantiated at this time.
No deficiencies were cited during this visit.

An exit interview was conducted, and a copy of this report was reviewed and provided to Caregiver Yasmin Aguirre, whose signature on this form confirm receipt of the above-mentioned documents.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Rohit Lama
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 18-AS-20220222130445
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
RIVERSIDE, CA 92507

FACILITY NAME: CHANTILLY LACE MANOR IV
FACILITY NUMBER: 361800121
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/01/2022
Section Cited
CCR
87307(a)(2)(B)
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No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage storage area, shed or similar detached building.
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Licensee shall agree that prior to accepting new residents they will ensure that the residence's room is ready. Licensee shall also read regulation 87307 in its entirety. Licensee shall provide proof of correction by submitting email confirming review of the section mentioned above to LPA by 3/7/22.
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Based on interviews and record review the licensee did not provide adequate sleeping arangements for residents, which poses a potential health and safety risk to resident(s) in care.
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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.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Rohit Lama
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5