Chantilly Lace Manor IV

Allegation investigated: Staff did not prevent resident from developing a pressure injury Staff do not ensure that medications are stored inaccessible to residents Staff do not assist residents with obtaining medical care Staff do not ensure that residents' dietary needs are met Licensee does not ensure that staff have required training Staff did not maintain facility in good repair Staff are not distributing resident's medication as prescribed

On 7/23/2026 at 2:50PM, Licensing Program Analysts (LPAs) Eldin Serrano and Matthew Aguilar made an unannounced visit to the facility to investigate and deliver the findings of the above allegations. LPAs met with caregiver Carmen Enriquez to explain the purpose of the visit. The investigation consisted of file review, interviews with facility staff and residents as well as facility observation. Allegation #1: Staff did not prevent resident from developing a pressure injury –Based on interviews and review of records, it was determined that the residents identified in the allegation were receiving services from an outside vendor. Therefore, the allegation is unsubstantiated. Allegation #2: Staff do not ensure that medications are stored inaccessible to residents - Based on LPA observation, medications were stored in a locked closet that required a key to access. LPA is unable to corroborate the allegation. *** Continuation in LIC9099C *** Unsubstantiated Allegation #3: Staff do not assist residents with obtaining medical care - Based on interviews and review of records, it was determined that the facility utilizes an outside vendor to provide care for residents whose needs exceed the skill level of facility staff. Therefore, the allegation cannot be corroborated. Allegation #4: Staff do not ensure that residents' dietary needs are met – Based on LPA observation and review of records, it was determined that the facility has sufficient food supplies and provides a balanced diet that meets the residents’ dietary needs. LPA is unable to corroborate the allegation. Allegation #5: Licensee does not ensure that staff have required training – Based on a review of records, it was confirmed that facility staff have the required training to perform their duties. The facility provided proof of the training conducted. Therefore, the allegation is unsubstantiated. Allegation #6: Staff did not maintain facility in good repair – Based on interviews and observation, it was determined that the bed alleged to be in disrepair was found to be in good condition and in good repair and did not pose any safety concerns to residents. Therefore, the allegation is unsubstantiated. Allegation #7: Staff are not distributing resident's medication as prescribed – Based on observation, record review, and medication audit, it was confirmed that medications were administered on time and as prescribed. Therefore, the allegation is unsubstantiated. Information received during investigation LPA did not find evidence to corroborate the allegations. Based on the evidence, record review and interview, the allegations mentioned above are UNSUBSTANTIATED. A finding that the complaint is 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, therefore the allegation is unsubstantiated at this time. An exit interview was conducted where this report, LIC9099 and LIC9099C were discussed and provided to caregiver Carmen Enriquez.the state’s words, verbatim · CDSS document, Jul 23, 2026 · control 56-AS-20251007081521

Allegation investigated: Licensee did not ensure that facility staff who provided medical care to residents were appropriately skilled professionals Facility staff inappropriately restrained resident

On 4/27/2026 at 9:40 AM, Licensing Program Analyst (LPA) Eldin Serrano made an unannounced visit to the facility to deliver the findings of the above allegation. LPA explained the purpose of the visit to house manager Stephanie Smith. The investigation consisted of record review, interviews with staff and resident as well as observation. Allegation #1: Licensee did not ensure that facility staff who provided medical care to residents were appropriately skilled professionals – Based on interviews and a review of documentation, it was determined that R2’s insulin was being administered by the resident’s family member. The LPA also confirmed that some residents receive care from external providers. Allegation #2 Facility staff inappropriately restrained resident – LPA observed that R3 was not restrained during the visit. Interviews confirmed that facility staff do not utilize restraints on the residents in care. During the investigation, LPA did not find evidence to corroborate the allegations. *** Continuation in LIC9099C *** Unsubstantiated Based on the evidence, the allegations mentioned above are UNSUBSTANTIATED. A finding that the complaint is 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, therefore the allegation is unsubstantiated at this time. An exit interview was conducted where this report, LIC9099 and LIC9099C were discussed and provided to house manager Stephanie Smith.the state’s words, verbatim · CDSS document, Apr 27, 2026 · control 56-AS-20250929120855

Type of visit: Required - 1 Year

On 12/5//2025 at 9:15 AM, Licensing Program Analysts (LPAs) Eldin Serrano, Magda Malcore and Andrew Martinez made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with house manager Stephanie Smith and was granted entry to the facility. At the time of the visit there was one (1) staff, and five (5) residents present. The facility is a four (4) bedroom, three (3) bathroom home with a kitchen/dining area, living room/activity room. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of 6 and which five (5) non-ambulatory and six (6) hospice care waiver and 1 maybe bedridden and the current census is five (5) residents. LPAs were accompanied by a staff to conduct a general overall inspection, which included, but was not limited to the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). 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 the required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPAs observed sufficient furniture and lighting throughout the facility. LPAs measured and observed the water temperatures in the bathroom to be at 110 degrees Fahrenheit. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Fire extinguisher was also observed at the facility. Posters such as personal rights, the CCLD complaint poster, and the disaster plan were posted in a common area. ***Continuation in LIC809C *** Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for resident/staff files. There is a Medicine closet with the resident’s medications locked. LPAs observed first aid kit and manual. Yards/Outside: One shaded patio, two (2) side gates with self-latching handles on both side of the house that leads into the backyard, attached two (2) car garage observed. All outdoor pathways were free of obstructions. Food Service: Seven (7) days’ supply of Non-perishable foods and two (2) days’ supply of perishable food supply were observed and sufficient for the number of residents in care. LPA observed that the facility has the 72 hour emergency food and water. Care & Supervision: The facility has an Administrator present in the facility with enough hours to appropriately manage the facility. The facility has sufficient number of staff to provide care and supervision to the residents in care. Also, LPAs observed that the facility has dementia residents. Record Review: LPAs reviewed three (3) resident files for admission agreements, updated physician reports, pre-placement appraisals and needs and services plans. LPAs observed resident files reviewed were complete. LPAs reviewed three (3) staff files for First Aid/CPR certifications, criminal record clearances, trainings, and health screenings. LPAs observed that staff #1,#2 (S1,S2) do not have health screening reports available for review. Deficiency issued. LPAs observed that staff #3 (S3) do not have the required CPR/First aid training. Deficiency issued. Based on the observations made during today’s visit, two (2) deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report LIC809, LIC909C, LIC809D forms, and Appeal Rights were discussed and provided to House Manager Stephanie Smith.the state’s words, verbatim · CDSS document, Dec 5, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Michelle Echeverria made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Caregiver, Stephanie Smith and was granted entry to the facility. LPA was accompanied by Stephanie to conduct a general overall inspection, which included, but was not limited to, the following: The facility has 4 bedrooms, 3 bathrooms, kitchen, dining area, living room, entry room, laundry room, garage and backyard. LPA 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. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected resident bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 119 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, CCL complaint poster, ombudsman, and license were posted in a common area. Cleaning supplies, toxins, sharps, medications and other dangerous items were kept in secure cabinets inaccessible to residents. Residents/Staff files were observed locked and made inaccessible. There are no bodies of water, 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: LPA observed 2 days of perishables and 7 days non-perishables food, pantry stocked and up to date. Facility has a variety of food available. Dishes, cups, and utensils were stored properly. Yards/Outside: One shaded patio, a side gate with entrance/exit to the facility on the left and right side. All outdoor pathways were free of obstructions. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. Record Review: LPA reviewed resident files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. Medication was audited and matched with record. LPA reviewedemergency disaster plan and disaster drills. LPA observed that the facility did not have a copy of the report sent to the local fire jurisdiction about oxygen used in the facility. Technical violation issued. LPA observed that the bedrooms with oxygen did not have oxygen in use signs. Technical violation issued. No deficiencies and two technical violations were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, and LIC9102TV were discussed and copies were provided to caregiver, Stephanie Smith.the state’s words, verbatim · CDSS document, Nov 15, 2024

Type of visit: POC

Licensing Program Analyst (LPA) Michelle Echeverria arrived at the facility unannounced on 2/7/24 and was granted entry by caregiver, Stephanie Smith. LPA explained the purpose of today's visit to Smith. The purpose of today's visit was to follow-up on Plan of Correction (POC) previously due on 02/02/2024 for deficiencies cited on form LIC9099-D issued on 01/24/2024. Smith then phoned the administrator, Teresa Baddeley to notify her about the visit. The following deficiency was not corrected by the POC due date nor at the time of this visit. Civil penalties are being assessed and will continue to accrue until correction has been submitted: Deficiency cited under Title 22 Regulation 87465(b) and POC was for Licensee to hold a training with staff and submit proof to LPA via email by 02/02/24. Proof of training was not received. LPA spoke to the administrator over the phone and stated that she did not submit a POC since she was appealing the deficiency cited. Civil penalties assessed today at the rate of $100 per day per citation per violation per day until the violation is corrected. Exit interview conducted with and a copy of this report, LIC421FC, and appeal rights were provided to Stephanie Smith.the state’s words, verbatim · CDSS document, Feb 7, 2024

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Michelle Echeverria conducted an unannounced case management visit to the facility during a plan of correction (POC) visit. During the visit, LPA observed cameras in the residents bedrooms, dining room and living room. LPA also observed the main entrance being restricted to all residents in care by not allowing them to enter and exit the facility without an access code entered on the door knob. During today’s visit, deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted where this report LIC809, LIC809D, and appeal rights were discussed and provided to Stephanie Smith.the state’s words, verbatim · CDSS document, Feb 7, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a) · Plan of correction due date: Feb 8, 2024

87468.2(a) 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......personal rights: This requirement is not met as evidenced by: Based on observation, the administrator did not comply with the section cited above by violating the personal rights for residents with the cameras installed in their bedrooms which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 7, 2024

Plan of correction: Administrator stated that she will review regulation CCR 87468.2(a) and submit a statement of understanding to LPA via email by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87705(l) · Plan of correction due date: Feb 8, 2024

87705(l) Care of Persons with Dementia (l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: This requirement is not met as evidenced by: Based on observation, the administrator did not comply with the section cited above by restricting access to entering and exiting the main entrance door by requiring a code to be entered which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 7, 2024

Plan of correction: Administrator stated that she will replace the door knob that has a code with one that doesn't have a code. Administrator stated that she will submit a statement of understanding to LPA via email by 2/8/24.

Type of visit: Required - 1 Year

On 11/22/23, Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with caregiver, Christina Bratton, and introduced self and stated purpose of the visit. LPA was informed that there are 6 residents in care. The facility has 4 bedrooms, 3 bathrooms, kitchen, dining area, living room, entry room, laundry room, garage and backyard. LPA completed a walk through of facility and review of records. 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 73 degrees fahrenheit. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA observed video cameras inside the residents bedrooms. Deficiency issued. LPA inspected resident bathrooms; bathrooms were clean and appliances were found functional. LPA observed a missing non-skid mat in one of the bathrooms. Deficiency issued. Water temperatures tested at 119.4 degrees fahrenheit. The facility is equipped with operational smoke detectors and charged fire extinguisher. LPA observed non-functioning carbon monoxide alarms. Deficiency issued. Posters such as; the personal rights, ombudsman, CCL complaint poster and disaster plans were posted in a common area. LPA observed the emergency disaster plan on an outdated form. Technical violation issued. Cleaning supplies, toxins, sharps, and other dangerous items were not all kept in secure cabinets. Deficiency issued. There was a designated storage space for resident/staff files. Medications and first aid kit were observed and inaccessible to residents. LPA observed a broken cabinet beneath the kitchen sink and broken counter top. Deficiency issued. LPA also observed the main entrance door with restricted exit access due to code needed in order enter/exit the facility. Deficiency issued. Food Service: Non-perishable and perishable food supply is sufficient. Facility has a wide variety of food available. Dishes, cups, and utensils were also stored properly. Yards/Outside: One shaded patio, a side gate with entrance/exit to the facility on the left and right side. All outdoor pathways were free of obstructions. Record Review: LPA reviewed administrator's and staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA observed incomplete personnel records. Deficiency issued. LPA observed that one staff was not associated to the facility and did not have transfer of criminal record clearance. Deficiency with civil penalty issued. LPA was prohibited to review resident records and was not given access. Deficiency issued. LPA observed through interview with administrator, Teresa Baddeley that the facility did not have an Infection Control Plan. Deficiency issued. Deficiencies, technical violation and civil penalty were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC9102TV, LIC421BG and appeal rights were discussed and copies were provided to caregiver, Heilala Poloa who took over the next shift since caregiver's Christina Bratton's shift had ended.the state’s words, verbatim · CDSS document, Nov 22, 2023

The state marks this report as 9 pages; the online copy we transcribed has 8. You can request the full file from the county licensing office.