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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426709
Report Date: 01/24/2024
Date Signed: 01/24/2024 02:17:27 PM


Document Has Been Signed on 01/24/2024 02:17 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 MANOR IIFACILITY NUMBER:
366426709
ADMINISTRATOR:BADDELEY, TERESAFACILITY TYPE:
740
ADDRESS:8430 "I" AVENUETELEPHONE:
(760) 956-5375
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY:6CENSUS: 6DATE:
01/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:24 AM
MET WITH:Teresa Baddeley- LicenseeTIME COMPLETED:
02:25 PM
NARRATIVE
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On 1/24/24, Licensing Program Analysts (LPAs) Michelle Echeverria and Anna Bueno arrived unannounced to conduct the required annual visit to the facility. LPAs met with Licensee, Teresa Baddeley and introduced self and stated purpose of the visit. LPAs were informed that there are currently 6 residents in care.

The facility has 5 bedrooms, 3 bathrooms, 2 kitchens, dining area, living room, family room, sitting room, office, laundry/medication room, attached garage and backyard. LPAs completed a walk through of facility, review of records and medication audit.

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 74 degrees fahrenheit. LPAs inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPAs inspected resident bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 109 degrees fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms, charged fire extinguisher and first aid kit. Posters such as; the personal rights, emergency disaster plan, CCL complaint poster and ombudsman were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept locked and inaccessible to residents. There was a designated storage space for resident/staff files. Medications were observed locked and inaccessible to residents. There is no swimming pool, firearms or ammunition in the facility. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care.

Food Service: Non-perishable and perishable food supply is sufficient for residents in care. Dishes, cups, and utensils were also stored properly.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle EcheverriaTELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2024
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 4


Document Has Been Signed on 01/24/2024 02:17 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 MANOR II
FACILITY NUMBER: 366426709

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(c)(1)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. (1) The Infection Control Plan shall include all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in submitting a complete Infection Control Plan which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/02/2024
Plan of Correction
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Licensee states that she will review and submit a complete Infection Control Plan to LPA via email by POC due date.
Type B
Section Cited
CCR
87465(h)(4)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above by storing expired medication and accepting medication with altered labels which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/02/2024
Plan of Correction
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Licensee states that she will discard the expired medication and deny any altered label medications. Licensee will conduct a training with staff and submit proof to LPA via email by POC due date.
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: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle EcheverriaTELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 01/24/2024 02:17 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 MANOR II
FACILITY NUMBER: 366426709

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(c)(3)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in not maintaining a log for two different PRN medications for two different residents which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/02/2024
Plan of Correction
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Licensee states that she will train staff on the regulation cited above and submit a statement of understanding to LPA via email by POC due date.
Type B
Section Cited
HSC
1569.695(d)
Other Provisions
(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in maintaining a complete Emergency Disaster Plan which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/02/2024
Plan of Correction
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Licensee states that she will review and submit a complete Emergency Disaster Plan to LPA via email by POC due date.
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: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle EcheverriaTELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 MANOR II
FACILITY NUMBER: 366426709
VISIT DATE: 01/24/2024
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Yards/Outside: One shaded patio, side gate with self-latching handle on the left and right side of the house that leads into the backyard.

Record Review: LPAs reviewed staff and administrator files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPAs reviewed resident files for admission agreements, updated physician reports, and needs and services plans. LPAs reviewed medication and observed altered labels, expired medication and medication not logged. Deficiencies issued. LPAs observed the Emergency Disaster Plan and Infection Control Plan incomplete. Deficiencies issued.

Deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D and appeal rights were discussed and copies were provided to Licensee, Teresa Baddeley.

SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle EcheverriaTELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4