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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361800121
Report Date: 04/27/2026
Date Signed: 04/27/2026 10:14:35 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 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
09/29/2025 and conducted by Evaluator Eldin Serrano
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20250929120855
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:
04/27/2026
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Stephanie Smith, House ManagerTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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9
Licensee did not ensure that facility staff who provided medical care to residents were appropriately skilled professionals
Facility staff inappropriately restrained resident
INVESTIGATION FINDINGS:
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On 4/27/2026 at 9:40 AM, Licensing Program Analyst (LPA) Eldin Serrano made an unannounced visit to the facility to deliver the findings of the above allegation. LPA explained the purpose of the visit to house manager Stephanie Smith. The investigation consisted of record review, interviews with staff and resident as well as observation.
Allegation #1: Licensee did not ensure that facility staff who provided medical care to residents were appropriately skilled professionals – Based on interviews and a review of documentation, it was determined that R2’s insulin was being administered by the resident’s family member. The LPA also confirmed that some residents receive care from external providers.

Allegation #2 Facility staff inappropriately restrained resident – LPA observed that R3 was not restrained during the visit. Interviews confirmed that facility staff do not utilize restraints on the residents in care.

During the investigation, LPA did not find evidence to corroborate the allegations.
*** Continuation in LIC9099C ***
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2026
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 2
Control Number 56-AS-20250929120855
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: CHANTILLY LACE MANOR IV
FACILITY NUMBER: 361800121
VISIT DATE: 04/27/2026
NARRATIVE
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Based on the evidence, the allegations mentioned above are UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means 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.

An exit interview was conducted where this report, LIC9099 and LIC9099C were discussed and provided to house manager Stephanie Smith.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2