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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366425325
Report Date: 07/29/2021
Date Signed: 07/29/2021 10:14:41 AM

Unfounded


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
01/02/2020 and conducted by Evaluator Stephanie Torres
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200102162034
FACILITY NAME:CHANTILLY LACE MANORFACILITY NUMBER:
366425325
ADMINISTRATOR:TERESA BADDELEYFACILITY TYPE:
740
ADDRESS:7421 MINSTEAD AVETELEPHONE:
(760) 552-9980
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY:6CENSUS: 6DATE:
07/29/2021
UNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:House Manager, Carol Canto-Hamilton,TIME COMPLETED:
10:15 AM
ALLEGATION(S):
1
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9
Provider is disregarding a treatment plan made between the resident and their medical doctor.
Provider refused to allow the resident to leave the facility.
INVESTIGATION FINDINGS:
1
2
3
4
5
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13
Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to deliver the findings of the investigation on the above allegations. The LPA met with House Manager, Carol Canto-Hamilton, and informed her of the purpose of the visit.

Pertaining to the allegation, "Provider is disregarding a treatment plan made between the resident and their medical doctor," it was alleged Licensee, Teresa Baddeley, cancelled Resident One's (R1's) physical therapy and their transfer to inpatient rehabilitation. The LPA initiated the investigation on January 08, 2020; the LPA conducted interviews, reviewed records, and took copies of pertinent documentation. Records from R1's Primary Care Provider were obtained; a Health Advocate Post Discharge Communication note, dated December 20, 2019, revealed R1 did show interest in receiving physical therapy, however, they also had a desire to remain in the facility. Licensee Baddeley was interviewed and denied the allegation; she reported R1 was observed crying and stating they did not want to leave the facility. R1 was interviewed and corroborated the Licensee's statement. Therefore, based on interviews and records, this allegation is deemed
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Stephanie Torres
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021
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 4
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
01/02/2020 and conducted by Evaluator Stephanie Torres
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200102162034

FACILITY NAME:CHANTILLY LACE MANORFACILITY NUMBER:
366425325
ADMINISTRATOR:TERESA BADDELEYFACILITY TYPE:
740
ADDRESS:7421 MINSTEAD AVETELEPHONE:
(760) 552-9980
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY:6CENSUS: 6DATE:
07/29/2021
UNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:House Manager, Carol Canto-Hamilton,TIME COMPLETED:
10:15 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Provider falsified documents.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to deliver the findings of the investigation on the above allegations. The LPA met with House Manager, Carol Canto-Hamilton, and informed her of the purpose of the visit.

Regarding the allegation, "Provider falsified documents," it was alleged Licensee, Baddeley, falsified medical diagnoses in order to register Resident One (R1) to receive Hospice services. Baddeley was interviewed and denied the allegation. Hospice medical records were obtained; an admission note report revealed the condition for which R1 qualified to receive hospice services was not listed as a previous condition. An interview was conducted with a representative of the Department of Public Health (DPH); it was reported two (2) physicians must agree an individual is terminal for the person to be admitted onto Hospice services for their first time. Third party interviews were conducted; it was reported the Licensee did not falsify documents and R1's hospice admission was valid. However, it was reported R1 was diagnosed terminal and admitted onto services by only one (1) physician. Therefore, due to insufficient information, this allegation is deemed UNSUBSTANTIATED at
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Stephanie Torres
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 18-AS-20200102162034
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
FACILITY NUMBER: 366425325
VISIT DATE: 07/29/2021
NARRATIVE
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this time. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No citations have been issued at this time.

This report was reviewed with House Manager, Carol Canto-Hamilton, and a copy was provided.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Stephanie Torres
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 18-AS-20200102162034
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
FACILITY NUMBER: 366425325
VISIT DATE: 07/29/2021
NARRATIVE
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UNFOUNDED.

With regard to the allegation, "Provider refused to allow the resident to leave the facility," it was alleged Licensee, Baddeley, refused to allow R1 to leave the facility to receive treatment at a Skilled Nursing Facility (SNF) on December 31, 2019. Baddeley was interviewed and denied the allegation; she reported R1 chose not to leave the facility on this date. R1 was interviewed and corroborated the Licensee's statement. Medical records were requested and received; a Health Advocate Post Discharge Communication note reported R1 did notify their primary care office they did not want to transfer out of the facility. Therefore, based on interviews and records review, this allegation is deemed UNFOUNDED.

A finding that the complaint is unfounded means that the allegations are false, could not have happened, and/or are without a reasonable basis. No citations have been issued at this time.

This report was reviewed with Canto-Hamilton and a hard copy was provided.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Stephanie Torres
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4