366426709-1-24-2024-56-AS-NBRN-D2GTA2-20240215133248

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366426709
Report Date: 01/24/2024
Date Signed: 01/24/2024 02:22:15 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
01/17/2024 and conducted by Evaluator Anna Bueno

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20240117121300

FACILITY NAME:	CHANTILLY LACE MANOR II		FACILITY NUMBER:	366426709
ADMINISTRATOR:	BADDELEY, TERESA		FACILITY TYPE:	740
ADDRESS:	8430 "I" AVENUE		TELEPHONE:	(760) 956-5375
CITY:	HESPERIA	STATE: CA	ZIP CODE:	92345
CAPACITY:	6	CENSUS: 6	DATE:	01/24/2024
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Teresa Baddeley		TIME COMPLETED:	02:24 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff did not seek timely medical attention for a resident.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analysts (LPAs) Anna Bueno and Michelle Echeverria conducted an unannounced visit to this facility for the purpose of initiating the investigation of and delivering findings for the above allegation. LPAs met with licensee Teresa Baddeley who was advised of the purpose of visit. The investigation consisted of records review and interviews with relevant parties.

It is alleged that Resident 1 (R1) was not provided timely medical attention by facility staff. LPA Bueno conducted interviews that revealed that R1's change of condition was observed by Witness 1 (W1) who reported the change to their agency and to facility staff. Interviews further revealed R1 was not seen by any medical personnel from the outside agency providing R1 with services. Records reviewed also revealed that R1 was receiving services from an outside agency when their condition was observed by W1 and that R1 was taken to the local hospital for treatment on the same day R1's condition was observed. This allegation is therefore unsubstantiated.

A finding of UNSUBSTANTIATED means although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted with Licensee and a copy of this report was provided.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna Bueno	TELEPHONE: 951-204-4307
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.

LIC9099 (FAS) - (06/04)

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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
01/17/2024 and conducted by Evaluator Anna Bueno

COMPLAINT CONTROL NUMBER: 56-AS-20240117121300

FACILITY NAME:	CHANTILLY LACE MANOR II		FACILITY NUMBER:	366426709
ADMINISTRATOR:	BADDELEY, TERESA		FACILITY TYPE:	740
ADDRESS:	8430 "I" AVENUE		TELEPHONE:	(760) 956-5375
CITY:	HESPERIA	STATE: CA	ZIP CODE:	92345
CAPACITY:	6	CENSUS: 6	DATE:	01/24/2024
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Teresa Baddeley		TIME COMPLETED:	02:24 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff did not dispense medications as prescribed.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analysts (LPAs) Anna Bueno and Michelle Echeverria conducted an unannounced visit to this facility for the purpose of initiating the investigation of and delivering findings for the above allegation. LPAs met with licensee Teresa Baddeley who was advised of the purpose of visit. The investigation consisted of observations of the physical plant, records review and interviews with relevant parties.

It is alleged that facility staff did not dispense medications as prescribed. LPAs reviewed records, inspected medication, and observed three residents medications were not listed in the centrally stored medication list. LPAs observed two of the above mentioned three medications are filled in bubble packs with a few empty bubbles in either packs. This allegation is therefore substantiated.This poses a potential health and safety risk to residents in care.

A finding that the complaint is SUBSTANTIATED means that the allegation is valid as the preponderance of the evidence standard has been met. Refer to LIC809-D for deficiency cited. An exit interview was conducted where this report, LIC809-D, and appeal rights were provided to licensee Baddeley.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna Bueno	TELEPHONE: 951-204-4307
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.

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Citations on this Visit Report are Under Appeal!

Control Number 56-AS-20240117121300

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: 01/24/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Under Appeal Type B 02/02/2024 Section Cited CCR 87265(d)(3)	1 2 3 4 5 6 7	(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.	1 2 3 4 5 6 7	Licensee shall conduct an audit of all resident medications and complete a completed list of all resident medications. Licensee shall submit proof of correction to the Department no later than end of POC date.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: LPAs inspected resident medications and centralized record and found three medications not listed on the centralized record. Two of three medications appeared to have been administered, which poses a potential health and safety risk to clients 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: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna Bueno	TELEPHONE: 951-204-4307
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

LIC9099 (FAS) - (06/04)

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