361800121-7-23-2026-56-AS-KCLS-DWEMF6-20260728093345

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361800121
Report Date: 07/23/2026
Date Signed: 07/23/2026 03:19:10 PM

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
10/07/2025 and conducted by Evaluator Eldin Serrano

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20251007081521

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: 5	DATE:	07/23/2026
		UNANNOUNCED	TIME BEGAN:	02:50 PM
MET WITH:	Carmen Enriquez Caregiver		TIME COMPLETED:	03:35 PM

ALLEGATION(S):

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Staff did not prevent resident from developing a pressure injury
Staff do not ensure that medications are stored inaccessible to residents
Staff do not assist residents with obtaining medical care
Staff do not ensure that residents' dietary needs are met
Licensee does not ensure that staff have required training
Staff did not maintain facility in good repair
Staff are not distributing resident's medication as prescribed

INVESTIGATION FINDINGS:

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On 7/23/2026 at 2:50PM, Licensing Program Analysts (LPAs) Eldin Serrano and Matthew Aguilar made an unannounced visit to the facility to investigate and deliver the findings of the above allegations. LPAs met with caregiver Carmen Enriquez to explain the purpose of the visit. The investigation consisted of file review, interviews with facility staff and residents as well as facility observation.

Allegation #1: Staff did not prevent resident from developing a pressure injury –Based on interviews and review of records, it was determined that the residents identified in the allegation were receiving services from an outside vendor. Therefore, the allegation is unsubstantiated.

Allegation #2: Staff do not ensure that medications are stored inaccessible to residents - Based on LPA observation, medications were stored in a locked closet that required a key to access. LPA is unable to corroborate the allegation.

*** Continuation in LIC9099C ***

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 56-AS-20251007081521

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: 07/23/2026

NARRATIVE

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Allegation #3: Staff do not assist residents with obtaining medical care - Based on interviews and review of records, it was determined that the facility utilizes an outside vendor to provide care for residents whose needs exceed the skill level of facility staff. Therefore, the allegation cannot be corroborated.

Allegation #4: Staff do not ensure that residents' dietary needs are met – Based on LPA observation and review of records, it was determined that the facility has sufficient food supplies and provides a balanced diet that meets the residents’ dietary needs. LPA is unable to corroborate the allegation.

Allegation #5: Licensee does not ensure that staff have required training – Based on a review of records, it was confirmed that facility staff have the required training to perform their duties. The facility provided proof of the training conducted. Therefore, the allegation is unsubstantiated.

Allegation #6: Staff did not maintain facility in good repair – Based on interviews and observation, it was determined that the bed alleged to be in disrepair was found to be in good condition and in good repair and did not pose any safety concerns to residents. Therefore, the allegation is unsubstantiated.

Allegation #7: Staff are not distributing resident's medication as prescribed – Based on observation, record review, and medication audit, it was confirmed that medications were administered on time and as prescribed. Therefore, the allegation is unsubstantiated.

Information received during investigation LPA did not find evidence to corroborate the allegations.

Based on the evidence, record review and interview, 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 caregiver Carmen Enriquez.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2026

LIC9099 (FAS) - (06/04)

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