361800121-11-22-2023-56-AS-MECA-CXTW5H-20231122155909

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361800121
Report Date: 11/22/2023
Date Signed: 11/22/2023 03:59:23 PM

Document Has Been Signed on 11/22/2023 03:59 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 IV		FACILITY NUMBER:	361800121
ADMINISTRATOR:	BADDELEY, TERESA		FACILITY TYPE:	740
ADDRESS:	13365 HIDDEN VALLEY RD		TELEPHONE:	(760) 241-0991
CITY:	VICTORVILLE	STATE: CA	ZIP CODE:	92395
CAPACITY:	6	CENSUS: 6	DATE:	11/22/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Christina Bratton- Caregiver		TIME COMPLETED:	04:08 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 11/22/23, Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with caregiver, Christina Bratton, and introduced self and stated purpose of the visit. LPA was informed that there are 6 residents in care. The facility has 4 bedrooms, 3 bathrooms, kitchen, dining area, living room, entry room, laundry room, 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 73 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 video cameras inside the residents bedrooms. Deficiency issued. LPA inspected resident bathrooms; bathrooms were clean and appliances were found functional. LPA observed a missing non-skid mat in one of the bathrooms. Deficiency issued. Water temperatures tested at 119.4 degrees fahrenheit. The facility is equipped with operational smoke detectors and charged fire extinguisher. LPA observed non-functioning carbon monoxide alarms. Deficiency issued. Posters such as; the personal rights, ombudsman, CCL complaint poster and disaster plans were posted in a common area. LPA observed the emergency disaster plan on an outdated form. Technical violation issued. Cleaning supplies, toxins, sharps, and other dangerous items were not all kept in secure cabinets. Deficiency issued. There was a designated storage space for resident/staff files. Medications and first aid kit were observed and inaccessible to residents. LPA observed a broken cabinet beneath the kitchen sink and broken counter top. Deficiency issued. LPA also observed the main entrance door with restricted exit access due to code needed in order enter/exit the facility. Deficiency issued.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2023

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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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: 11/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.311

Regulations

Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the administrator did not comply with the section cited above in having functioning carbon monoxide alarms which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/23/2023
	Plan of Correction
1 2 3 4	Administrator stated that she will purchase and install new carbon monoxide alarms and submit proof of receipt and picture to LPA via email by POC due date.

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the administrator did not comply with the section cited above in maintaining knives and chemicals inaccessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/22/2023
	Plan of Correction
1 2 3 4	Administrator locked knives and chemicals right away. Administrator stated that she will submit a statement of understanding on regulation CCR 87309(a) to LPA via email by 12/06/2023.

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	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2023

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 IV	FACILITY NUMBER: 361800121
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(3)

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: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the administrator did not comply with the section cited above in having a transfer request of criminal record clearance which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/23/2023
	Plan of Correction
1 2 3 4	Administrator stated that she will submit a transfer of criminal record clearance; associate staff to facility on Guardian and submit proof to LPA via email by POC due date.

Type A

Section Cited

CCR

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:
	Deficient Practice Statement
1 2 3 4	Based on observation, the administrator did not comply with the section cited above in restricting access to 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.
	POC Due Date: 11/22/2023
	Plan of Correction
1 2 3 4	Administrator removed code on main entrance door and now anyone inside facilty can exit at any time. Administrator stated that she will submit a statement of understanding to LPA via email by 12/06/23.

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	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2023

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 IV	FACILITY NUMBER: 361800121
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87470(d)(6)

Infection Control Requirements

(d) When an emergency, as defined in Government Code section 8558, or federal emergency for a contagious disease is proclaimed or declared, the licensee shall develop an Emergency Infection Control Plan that includes infection control measures that are not already addressed in the Infection Control Plan as specified in subsection (c), to prevent, contain, and mitigate the associated contagious disease. (6) The Emergency Infection Control Plan shall be reviewed and updated as necessary or whenever new infection control measures are recommended by the federal, state, and local government public health authorities, or as determined by the Department, until the proclaimed or declared state of emergency is no longer in effect. Any updates to the plan shall be made available to staff, residents and if applicable, each resident’s representative, and submitted to the Department. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the administrator did not comply with the section cited above in providing an Infection Control Plan to LPA for inspection which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/06/2023
	Plan of Correction
1 2 3 4	Administrator stated that she will submit an Infection Control Plan to LPA via email by POC due date.

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	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2023

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 IV	FACILITY NUMBER: 361800121
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the administrator did not comply with the section cited above in maintaining a safe and in good repair facility which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/06/2023
	Plan of Correction
1 2 3 4	Administrator stated that she will have the cabinet beneath the sink and kitchen counter repaired and submit proof of picture to LPA via email by POC due date.

Type B

Section Cited

CCR

87303(e)(5)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the administrator did not comply with the section cited above in providing a non-skid mat for all bathrooms which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/06/2023
	Plan of Correction
1 2 3 4	Administrator stated that she will purchase a non-skid mat for the bathroom and submit proof of receipt and picture to LPA via email by POC due date.

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	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2023

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 IV	FACILITY NUMBER: 361800121
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(a)

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: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the administrator did not comply with the section cited above in maintaining complete personnel records which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/06/2023
	Plan of Correction
1 2 3 4	Administrator stated that she will have personnel complete their missing records and submit proof to LPA via email by POC due date.

Type B

Section Cited

CCR

87506(a)

Resident Records

(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview the administrator did not comply with the section cited above in prohibiting access to resident records for inspection to LPA which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/06/2023
	Plan of Correction
1 2 3 4	Administrator stated that she will submit a statement of understanding to LPA via email by POC due date.

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	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2023

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 IV	FACILITY NUMBER: 361800121
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

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, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	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 a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/06/2023
	Plan of Correction
1 2 3 4	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.

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.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2023

LIC809 (FAS) - (06/04)

Page: 7 of 9

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
	VISIT DATE: 11/22/2023

NARRATIVE

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Food Service: Non-perishable and perishable food supply is sufficient. Facility has a wide variety of food available. Dishes, cups, and utensils were also stored properly.

Yards/Outside: One shaded patio, a side gate with entrance/exit to the facility on the left and right side. All outdoor pathways were free of obstructions.

Record Review: LPA reviewed administrator's and staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA observed incomplete personnel records. Deficiency issued. LPA observed that one staff was not associated to the facility and did not have transfer of criminal record clearance. Deficiency with civil penalty issued. LPA was prohibited to review resident records and was not given access. Deficiency issued. LPA observed through interview with administrator, Teresa Baddeley that the facility did not have an Infection Control Plan. Deficiency issued.

Deficiencies, technical violation and 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, Heilala Poloa who took over the next shift since caregiver's Christina Bratton's shift had ended.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2023

LIC809 (FAS) - (06/04)

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