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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426709
Report Date: 03/19/2025
Date Signed: 03/19/2025 10:13:55 AM

Document Has Been Signed on 03/19/2025 10:13 AM - 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/
DIRECTOR:
BADDELEY, TERESAFACILITY TYPE:
740
ADDRESS:8430 "I" AVENUETELEPHONE:
(760) 956-5375
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
03/19/2025
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:19 AM
MET WITH:Heilala PoloaTIME VISIT/
INSPECTION COMPLETED:
10:17 AM
NARRATIVE
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Licensing Program Analysts (LPAs) Magda Malcore and Eldin Serrano conducted an unannounced Plan of Correction (POC) visit to the facility. LPAs met with Heilala Paola, Caregiver,were granted entry and explained the purpose of the visit. Licensee Teresa Baddeley arrived to the facility shortly after and explained the purpose of the visit.

On 02/12/25 deficiencies were cited during a facility inspection and correction plans were due on 03/10/25. As of today’s visit, the following deficiencies have not been cleared:
· a statement of understanding of regulation cited [87465(d)(3)] was not provided to the LPAs. Licensee Baddeley stated that once her appeal is denied she will provide the statement of understanding.
· a copy of resident #1 (R1) signed admission’s agreement was not provided to the LPAs during today's visit. The Licensee stated she will have the family signed the documentation and submit a picture of the signed document the LPA.
· LPAs observed that facility supplies and equipment were still stored in resident’s designated private bathroom closet.
· LPAs observed that surveillance cameras were still mounted in all residents’ bedrooms.

Civil penalties of $3600 were accessed today for failure to correct deficiencies due on 3/10/2025 and civil penalties will continue to accrue $100 per day per violation until proof of correction has been received.

An exit interview was conducted with the licensee. Copies of reports LIC809 & LIC421FC were provided with appeal rights to Licensee Baddeley at the conclusion of the visit.
Karen ClemonsTELEPHONE: (951) 248-0349
Magda MalcoreTELEPHONE: 951-248-0316
DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2025
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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