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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800121
Report Date: 02/07/2024
Date Signed: 02/07/2024 03:06:46 PM


Document Has Been Signed on 02/07/2024 03:06 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 IVFACILITY NUMBER:
361800121
ADMINISTRATOR:BADDELEY, TERESAFACILITY TYPE:
740
ADDRESS:13365 HIDDEN VALLEY RDTELEPHONE:
(760) 241-0991
CITY:VICTORVILLESTATE: CAZIP CODE:
92395
CAPACITY:6CENSUS: 6DATE:
02/07/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Stephanie Smith- CaregiverTIME COMPLETED:
03:12 PM
NARRATIVE
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Licensing Program Analyst (LPA) Michelle Echeverria conducted an unannounced case management visit to the facility during a plan of correction (POC) visit.

During the visit, LPA observed cameras in the residents bedrooms, dining room and living room. LPA also observed the main entrance being restricted to all residents in care by not allowing them to enter and exit the facility without an access code entered on the door knob.

During today’s visit, deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted where this report LIC809, LIC809D, and appeal rights were discussed and provided to Stephanie Smith.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle EcheverriaTELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 02/07/2024 03:06 PM - It Cannot Be Edited

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 IV
FACILITY NUMBER: 361800121

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/08/2024
Section Cited
CCR
87468.2(a)

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87468.2(a) Additional Personal Rights of Residents in Privately Operated Facilities
(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities......personal rights:
This requirement is not met as evidenced by:
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Administrator stated that she will review regulation CCR 87468.2(a) and submit a statement of understanding to LPA via email by POC due date.
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Based on observation, the administrator did not comply with the section cited above by violating the personal rights for residents with the cameras installed in their bedrooms which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
02/08/2024
Section Cited
CCR87705(l)

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87705(l) Care of Persons with Dementia
(l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates:
This requirement is not met as evidenced by:
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Administrator stated that she will replace the door knob that has a code with one that doesn't have a code. Administrator stated that she will submit a statement of understanding to LPA via email by 2/8/24.
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Based on observation, the administrator did not comply with the section cited above by restricting access to entering and exiting the main entrance door by requiring a code to be entered which poses an immediate health, safety or personal rights risk to persons 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.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle EcheverriaTELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2