366426709-2-12-2025-56-AS-MMAE-DDU5WW-20250212191948

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366426709
Report Date: 02/12/2025
Date Signed: 02/12/2025 07:20:05 PM

Document Has Been Signed on 02/12/2025 07:20 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 II		FACILITY NUMBER:	366426709
ADMINISTRATOR/ DIRECTOR:	BADDELEY, TERESA		FACILITY TYPE:	740
ADDRESS:	8430 "I" AVENUE		TELEPHONE:	(760) 956-5375
CITY:	HESPERIA	STATE: CA	ZIP CODE:	92345
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	02/12/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:45 PM
MET WITH:	Teresa Baddeley		TIME VISIT/ INSPECTION COMPLETED:	07:25 PM

NARRATIVE

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Licensing Program Analyst (LPA) made an unannounced visit to the facility to conduct a required comprehensive annual inspection. LPA met with Licensee, Teresa Baddeley and caregiver, Carmen Enriquez. The facility is a Residential Care Facility for Elderly (RCFE) with a license capacity of (6), and a current census of (6). LPA conducted a general inspection of facility, which included, but was not limited to, the following:

Physical Plant: Indoor and outdoor passageways were kept free of obstruction. The facility has no swimming pools or similar bodies of water. The facility has sufficient indoor and outdoor space for resident activities. The facility is maintained at a comfortable temperature of 72 degrees F. Resident (5) bedrooms were furnished with beds, bedlinen, night stands, chairs, and lighting. LPA observed cameras mounted on the wall of each resident's bedroom. Resident (3) bathrooms were maintained clean and sanitary. The hot water temperatures in the bathrooms measured at 106 degrees F. LPA observed resident's private bathroom had a closet which was utilized to store facility's personal hygiene/incontinence products for all residents in care.

The facility is equipped with smoke detectors/carbon monoxide alarms, laundry equipment, cover fireplaces and telephone service. Posters such as personal rights, the Community Care Licensing complaint poster, Ombudsman poster, facility license and the disaster plan were posted. Cleaning supplies and sharps were kept inaccessible to residents in care.

Food Service: Kitchen and dining areas were maintained cleaned. Non-perishable and perishable food supply is sufficient for number of residents in care.

Medications/Health related services: Medications were centrally stored in a locked cabinet. LPA asked staff #4 (S4) to assist with providing resident medication administration logs. S4 stated that the facility does not maintain record/log of when medication is administered to residents. LPA asked staff for current medication list/record, S4 stated they were not familiar with how the facility manages the medication list since they are fill-in staff for that shift. **continued on LIC809-C**

Karen Clemons	TELEPHONE: (951) 248-0349
Magda Malcore	TELEPHONE: 951-248-0316
	DATE: 02/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2025

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

LIC809 (FAS) - (06/04)

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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: 02/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87465(d)(3)

Incidental Medical and Dental Care Services

(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to 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) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observations, the licensee did not comply with the section cited above by not maintaining a medication administration record/log; which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/10/2025
	Plan of Correction
1 2 3 4	The Licensee shall submit a statement of understanding of regulation cited to the licensing agency by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Karen Clemons	TELEPHONE: (951) 248-0349
Magda Malcore	TELEPHONE: 951-248-0316
	DATE: 02/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2025

LIC809 (FAS) - (06/04)

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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: 02/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87411(f)

Personnel Requirements - General

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA record review, the licensee did not comply with the section cited above by not maintaining a physical health record for S1, S2, S3 for review; which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/10/2025
	Plan of Correction
1 2 3 4	The Licensee shall submit documentation of staff's good physical health standing to the Licensing Agency by POC due date.

Section Cited

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Karen Clemons	TELEPHONE: (951) 248-0349
Magda Malcore	TELEPHONE: 951-248-0316
	DATE: 02/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2025

LIC809 (FAS) - (06/04)

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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: 02/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87308(c)

Resident and Support Services

(c) General storage space shall be maintained for equipment and supplies as necessary to ensure that space used to meet other requirements of these regulations is not also used for storage. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observations, the licensee did not comply with the section cited above by storing facility supplies in resident's private closet; which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/10/2025
	Plan of Correction
1 2 3 4	The Licensee shall submit to the licensing agency documentation of facility supplies removed to the Licensing Agency by plan of correction date.

Type B

Section Cited

CCR

87413(a)(1)

Personnel - Operations

(1) When regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observations; the licensee did not comply with the section cited above by fill-in staff was not sure of facility's medication record management; which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/10/2025
	Plan of Correction
1 2 3 4	The Licensee shall provide staff training of medication record management to the licensing agency 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.

Karen Clemons	TELEPHONE: (951) 248-0349
Magda Malcore	TELEPHONE: 951-248-0316
	DATE: 02/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/12/2025 07:20 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: 02/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87507(c)

Admission Agreements

(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above by authorized persons signatures missing on R1's admissions agreement documents; which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/10/2025
	Plan of Correction
1 2 3 4	The Licensee shall submit documentation of completed and signed resident's admissions agreement to the Licensing Agency by POC due date.

Type B

Section Cited

CCR

87468.2(a)(1)

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:(1)To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observations, the licensee did not comply with the section cited above by having cameras in resident's bedrooms; which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/10/2025
	Plan of Correction
1 2 3 4	The Licensee shall submit proof to the licensing agency of cameras removed from client bedrooms 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.

Karen Clemons	TELEPHONE: (951) 248-0349
Magda Malcore	TELEPHONE: 951-248-0316
	DATE: 02/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2025

LIC809 (FAS) - (06/04)

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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: 02/12/2025

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Record Review: LPA reviewed (3) resident files for admission agreements, updated physician reports, appraisals, and needs and services plans. LPA observed missing authorized persons signatures on several pages of Resident #1 (R1's) admissions agreement.

LPA reviewed (3) staff files for employment history, first Aid/CPR certifications, criminal record clearances, training, and health screenings. LPA observed staff#1 (S1), staff#2 (S2), and staff#3 (S3) did not have a complete health/physical screening for review.

Deficiencies are being cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted where reports (LIC809/LIC809-C/LIC809-D/ LIC9102) were discussed. Copies provided with appeal rights to Caregiver Enriquez at the conclusion of the visit.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2025

LIC809 (FAS) - (06/04)

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