<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366426709
Report Date: 05/08/2023
Date Signed: 05/08/2023 12:06:50 PM

Unsubstantiated


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
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/03/2023 and conducted by Evaluator Rayshaun Nickolas
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230503095510
FACILITY NAME:CHANTILLY LACE MANOR IIFACILITY NUMBER:
366426709
ADMINISTRATOR:BADDELEY, TERESAFACILITY TYPE:
740
ADDRESS:8430 "I" AVENUETELEPHONE:
(760) 956-5375
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY:6CENSUS: 6DATE:
05/08/2023
UNANNOUNCEDTIME BEGAN:
08:38 AM
MET WITH:Teresa Baddeley, LicenseeTIME COMPLETED:
12:11 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Uncleared staff are working at the facility.
Facility staff are not receiving adequate training.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Rayshaun Nickolas visited the facility unannounced to deliver the finding on the above allegations. LPA met with caregivers Shirley Becks and Christina Espinoza and explained the purpose of the visit. Becks’ called the Licensee Teresa Baddeley, and Baddeley arrived at the facility approximately 30 minutes later. The investigation included a facility tour, file reviews, and interviews with relevant parties.

Allegation #1: “Uncleared staff are working at the facility”. The allegation alleged that multiple employees at the facility do not have a background check. LPA Nickolas’ interview with the Licensee revealed that all employees have a criminal records clearance. LPA Nickolas’ file review revealed that all employees have a criminal record clearance with our agency. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation.

Allegation #2: “Facility staff are not receiving adequate training”. The allegation alleged that only one (1) day of training is provided at the facility.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Rayshaun NickolasTELEPHONE: 951-255-9516
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2023
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 5
Control Number 56-AS-20230503095510
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
, CA 92507
FACILITY NAME: CHANTILLY LACE MANOR II
FACILITY NUMBER: 366426709
VISIT DATE: 05/08/2023
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
26
27
28
29
30
31
32
LPA Nickolas' interview with the Licensee revealed that new employees are provided the recommended training outlined by the Title 22 California Code of Regulations (CCR). LPA Nickolas randomly audited four (4) out of six (6) employees' training records, which revealed that employees are provided 40 hours of training within 30 days of hire. LPA Nickolas' file audit also revealed that the facility provides all employees with 20 hours of annual training. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation.

A finding of 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.

An exit interview was conducted and copy of this report was provided.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Rayshaun NickolasTELEPHONE: 951-255-9516
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/03/2023 and conducted by Evaluator Rayshaun Nickolas
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230503095510

FACILITY NAME:CHANTILLY LACE MANOR IIFACILITY NUMBER:
366426709
ADMINISTRATOR:BADDELEY, TERESAFACILITY TYPE:
740
ADDRESS:8430 "I" AVENUETELEPHONE:
(760) 956-5375
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY:6CENSUS: 6DATE:
05/08/2023
UNANNOUNCEDTIME BEGAN:
08:38 AM
MET WITH:Teresa Baddeley, LicenseeTIME COMPLETED:
12:11 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff records are incomplete.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Rayshaun Nickolas visited the facility unannounced to deliver the finding on the above allegation. LPA met with caregivers Shirley Becks and Christina Espinoza and explained the purpose of the visit. Becks’ called the Licensee Teresa Baddeley, and the Licensee arrived at the facility approximately 30 minutes later. The investigation included a facility tour, file reviews, and interviews with relevant parties.

The allegation alleged that the facility's employees had no C&PR training and tuberculosis (TB) tests. LPA Nickolas' interview with the Licensee revealed that all employees must provide proof of CPR training and TB test before working at the facility. LPA Nickolas' file review revealed that five (5) of six (6) employees' files do not have proof of CPR training. LPA Nickolas' file review revealed that all six (6) employees do not have proof of TB tests.




Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Rayshaun NickolasTELEPHONE: 951-255-9516
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 56-AS-20230503095510
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
, CA 92507
FACILITY NAME: CHANTILLY LACE MANOR II
FACILITY NUMBER: 366426709
VISIT DATE: 05/08/2023
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
26
27
28
29
30
31
32
Based on the evidence gathered during the investigation, the above allegation is substantiated. A finding that the complaint is substantiated means that the allegation(s) is valid because the preponderance of the evidence standard has been met.

An exit interview was conducted where a copy of this report (LIC 9099), LIC 9099D, and appeal rights were discussed and provided.

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Rayshaun NickolasTELEPHONE: 951-255-9516
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 56-AS-20230503095510
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
, CA 92507

FACILITY NAME: CHANTILLY LACE MANOR II
FACILITY NUMBER: 366426709
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/15/2023
Section Cited
CCR
87411(c)(1)&(f)
1
2
3
4
5
6
7
87411 Personnel Requirements - General (c)(1)&(f)
Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.
(f) all personnel, including the licensee and administrator , shall be in good health...
1
2
3
4
5
6
7
Licensee shall submit proof of all employees first aide trainings and health screening to the regional office by the POC due date.
8
9
10
11
12
13
14
This requirement was not met as evidenced by:

Based on file review, the Licensee did not ensure that all employees file has proof of first aide training and TB test, which poses a potential health, safety, personal rights violations to persons in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Rayshaun NickolasTELEPHONE: 951-255-9516
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5