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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366425325
Report Date: 01/23/2024
Date Signed: 01/23/2024 12:31:53 PM

Document Has Been Signed on 01/23/2024 12:31 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 MANORFACILITY NUMBER:
366425325
ADMINISTRATOR:TERESA BADDELEYFACILITY TYPE:
740
ADDRESS:7421 MINSTEAD AVETELEPHONE:
(760) 552-9980
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY: 6CENSUS: 6DATE:
01/23/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Teresa Baddeley- AdministratorTIME COMPLETED:
12:38 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ryan Gardner conducted an unannounced case management visit to the facility during a complaint visit for control number 56-AS-20240117142158.

During the visit, LPA observed cameras in the resident’s bedrooms and camera monitoring in the laundry room which poses a potential health, safety, or personal rights risk to persons in care.

During today’s visit, one (1) deficiency was cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted where this report (LIC809), LIC809D, the appeal rights were discussed and provided to Teresa Baddeley.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2024
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 01/23/2024 12:31 PM - It Cannot Be Edited


Created By: Ryan Gardner On 01/23/2024 at 11:23 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CHANTILLY LACE MANOR
FACILITY NUMBER: 366425325

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/26/2024
Section Cited

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87209 Program Flexibility (a) The use of alternate concepts, programs, services, procedures, techniques, equipment, space, personnel qualifications or staffing ratios, or the conduct of experimental or demonstration projects shall not be prohibited by these regulations provided that: (2) A written request for a waiver or exception and substantiating evidence supporting the request shall be submitted in advance to the licensing agency by the applicant or licensee.
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This requirement is not met as evidenced based on observation and interview, the licensee did not comply with the section cited above evidenced by having cameras in the resident’s bedrooms without a written approval from the department which poses a potential health, safety, or personal rights risk to persons in care.
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The licensee has agreed to send a written request to have cameras in the resident's bedrooms and have approval from the department prior to installing the cameras in the resident’s bedrooms. The POC is due on 1/26/2024.

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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:Efren Malagon
LICENSING EVALUATOR NAME:Ryan Gardner
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2024


LIC809 (FAS) - (06/04)
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