Chantilly Lace Manor

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Magda Malcore and Eldin Serrano made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPAs met with Caregiver, Donna Norton and were granted entry to the facility. At the time of the visit there was one (1) staff, and five (5) residents present. Physical Plant: Indoor and outdoor passageways are free of obstructions. The facility is maintained at a comfortable temperature of 72 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 112 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 Ombudsman poster, labor law, facility license, and facility sketch were posted in a common area. Cleaning supplies, 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 medication room with the resident’s medications locked. LPAs observed first aid kit and manual. Yards/Outside: One shaded patio, one self-latching gate and an attached two (2) car garage was observed. 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. LPAs observed that the facility does not have enough emergency food and water for 72 hour emergency. Citation issued. 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. Based on the observations made during today’s visit, a deficiency was cited per Title 22, Division 6, of the California Code of Regulations and Health and Safety Code (HSC). An exit interview was conducted, and this report LIC809, LIC809C, LIC809D forms, and Appeal Rights were discussed and provided to Caregiver Norton.the state’s words, verbatim · CDSS document, Feb 27, 2026

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Staff forced a resident to take medication Staff administered another resident's prescribed medication to a resident Staff restrained a resident

Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced visit to the facility to conclude and deliver the findings on the above allegations. LPA was granted entry into the facility and met with Administrator, Teresa Baddeley. The investigation consisted of record review and interviews with pertinent parties. Regarding the allegation, staff forced a resident to take medication, interview with Resident #1 (R1) reveals that staff did not force them to take medication. Interviews with the Administrator and two (2) staff deny forcing any residents to take medications. Regarding the allegation, staff administered another resident's prescribed medication to a resident, review of resident’s medication records reveals medications were given as prescribed. Interviews with the Administrator and two (2) staff deny administering another resident’s prescribed medication to another resident. Unsubstantiated Regarding the allegation, staff restrained a resident, it was alleged that staff physically restrained R1. Interview with (R1) reveals they were not restrained by staff. Interviews with the Administrator and two (2) staff deny restraining any residents. Based on this department’s investigation, the allegations mentioned in this report are Unsubstantiated. An Unsubstantiated finding means although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted where this report was discussed, and a copy was provided with appeal rights to Administrator Baddeley at the conclusion of the visit.the state’s words, verbatim · CDSS document, Aug 21, 2025 · control 56-AS-20241107120742

Allegation investigated: Facility staff restrained a resident

Licensing Program Analyst (LPA) Magda Malcore and Licensing Program Manager, Karen Clemons conducted an unannounced complaint visit to the facility. The investigation consisted of observations, file review and interviews with pertinant parties. Regarding the allegation, facility staff restrained a resident, LPA observed resident #1 (R1) and resident #2 (R2) wearing lap belt retraints at the facility. Review of resident files reveals the resident #1 (R1), resident #2 (R2), and resident #3(R3) have physician's order to use gait belts. Based on the department's investigation, the allegation above is Unsubstantiated; meaning that 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. An exit interview was conducted where this report was discussed and a copy provided with appeal rights to Administrator Baddeley at the conclusion of the visit. Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 21, 2025 · control 56-AS-20250818103259

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with Caregiver, Donna Norton and introduced self and stated purpose of the visit. LPA was informed that there are currently 6 residents in care who are in the facility. LPA telephone called the Licensee, Teresa Baddeley and informed her about the purpose of the visit. The facility has 3 resident bedrooms, 1 staff bedroom, 2 bathrooms, kitchen, dining area, living room, family room, laundry room, attached 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 71 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 a resident occupying a staff bedroom without fire clearance approval. Deficiency issued. LPA inspected resident bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 120 degrees fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms, fire extinguisher and first aid kit. Posters such as; the ombudsman, administrator certificate and license were posted in a common area. LPA also observed cleaning supplies, toxins, sharps, and other dangerous items locked in cabinets made inaccessible to residents. There was a designated storage space for resident/staff files. Medications were observed secured and inaccessible to residents. There are no bodies of water, guns or ammunition in the facility. Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Facility has a wide variety of food available for residents. Dishes, cups, and utensils were also stored properly. Yards/Outside: One shaded patio, a side gate with self-latching handle on the right side of the house that leads into the backyard, and a attached garage used for storage. All outdoor pathways were free of obstructions. Record Review: LPA reviewed 3 resident files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed personnel and administrator files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA observed no health screening and TB for 1 caregiver. Deficiency issued. LPA observed a second caregiver arrive and assist residents without background clearance. LPA interviewed caregiver and stated that they had already worked 3 days prior. Deficiency with civil penalty issued. LPA reviewed the facility's insurance coverage, emergency disaster plan, infection control plan and emergency drills. LPA observed that the Infection Control Plan was not reviewed/updated annually. Technical violation issued. LPA observed that the Emergency Disaster Plan was not reviewed/updated annually. Technical violation issued. Deficiencies, two technical violations and one 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, Donna Norton.the state’s words, verbatim · CDSS document, Feb 7, 2025

The state marks this report as 6 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Facility staff did not dispense medications as prescribed. Facility staff withheld food from resident. Facility staff withheld water from resident. Facility staff is giving the residents alcohol. Facility staff is using a physical restraint on resident.

Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to investigate and deliver findings for the allegations listed above. LPA stated the purpose of the visit, was granted entry, and met with Administrator Teresa Baddeley. The investigation consisted of resident interviews, staff interviews, and document review. For allegation, Facility staff did not dispense medications as prescribed: Interviews with the staff revealed that the facility is dispensing the resident’s medication as prescribed. Prior to dispensing, the staff reads the resident’s prescription containers to ensure they are dispensing as ordered. The staff stated the process is to remove the medication out of the prescription containers, place the medications into a reusable cup container, and then immediately hand the cup container to the residents, and the staff verifies the resident took the medication. Once the resident takes the medication, the staff logs and initials the medication in the resident's MAR record. Unsubstantiated Interviews with the residents revealed that there were no known issues with medication not being dispensed as prescribed. Document review of the residents MARs records revealed that the resident’s medication is being documented appropriately. For allegation, Facility staff withheld food from resident: Interviews with the staff and the residents revealed that the residents are not being withheld food. The residents are served breakfast, lunch, dinner, and snacks throughout the day. The meals served include a mixture of fruits, vegetables, protein, and carbohydrates. If the residents are not full after a meal, additional food is available and offered until the resident is full. Document review of the facilities menu revealed that the facility offers a mixture of fruits, vegetables, protein, and carbohydrates three (3) times a day. The staff and the residents both denied that the residents are withheld food. For allegation, Facility staff withheld water from resident: Interviews with the staff and the residents revealed that the residents are not being withheld water. The residents are offered water throughout the day. The staff and the residents both denied that the residents are withheld water. For allegation, Facility staff is giving the residents alcohol: Interviews with the staff and the residents revealed that the residents on occasion are provided alcohol. The alcohol is only provided at resident’s request due to the resident having personal rights. During these occasions, it is usually during a holiday and or a celebration. The residents are only provided a small amount of alcohol. The staff only allows alcohol if the resident is not on a medication that will interact with the alcohol. For allegation, Facility staff is using a physical restraint on resident: Interviews with the staff and the residents revealed that the resident’s are not being physically restrained. The facility staff utilizes a gait belt to assist the residents with their transfers and mobility. The staff and the residents both denied that the residents are being physically restrained. Overall, there was not enough evidence to collaborate the allegations listed above. Based on evidence obtained during the investigation, the allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC9099) was discussed and provided Administrator Teresa Baddeley, along with a copy of the appeal rights.the state’s words, verbatim · CDSS document, Jan 23, 2024 · control 56-AS-20240117142158

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Ryan Gardner conducted an unannounced case management visit to the facility during a complaint visit for control number 56-AS-20240117142158. During the visit, LPA observed cameras in the resident’s bedrooms and camera monitoring in the laundry room which poses a potential health, safety, or personal rights risk to persons in care. During today’s visit, one (1) deficiency was cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted where this report (LIC809), LIC809D, the appeal rights were discussed and provided to Teresa Baddeley.the state’s words, verbatim · CDSS document, Jan 23, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87209(a)(2) · Plan of correction due date: Jan 26, 2024

87209 Program Flexibility (a) The use of alternate concepts, programs, services, procedures, techniques, equipment, space, personnel qualifications or staffing ratios, or the conduct of experimental or demonstration projects shall not be prohibited by these regulations provided that: (2) A written request for a waiver or exception and substantiating evidence supporting the request shall be submitted in advance to the licensing agency by the applicant or licensee. This requirement is not met as evidenced based on observation and interview, the licensee did not comply with the section cited above evidenced by having cameras in the resident’s bedrooms without a written approval from the department which poses a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 23, 2024

Plan of correction: The licensee has agreed to read regulation 87209 entirely and send LPA a statement of understanding that the regulation was read and understood. The licensee has agreed to remove the cameras from the resident’s bedrooms. The licensee has agreed to send a written request to have cameras in the resident's bedrooms and have approval from the department prior to installing the cameras in the resident’s bedrooms. The POC is due on 1/26/2024.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Mary Rico made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with care giver Alison D. Bowler and was granted entry to the facility. The facility is a (6) bedroom (2) bathroom home and, with a kitchen/dining area, living room, and attached garage. LPA was accompanied by Administrator Teresa Baddeley 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 (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, and sharps were kept inaccessible to clients in care. There was a designated space for client/staff files. Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a variety of food available for clients. Dishes, cups, and utensils were also stored properly. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. Record Review: LPA reviewed (4) resident files for admission agreements, updated physician reports, and needs and services plans. LPA reviewed (4) resident medications. During medication review, LPA observed lose medications and medications transferred between containers. LPA also reviewed (2) staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings. During record review, LPA observed S1 did not have a criminal record clearance. Administrator stated S1 did not have a criminal record clearance. S1 immediately left the facility. Based on the observations made during today’s visit, two (2) Type A deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. And a Civil Penalty in the amount of $500 dollars will be issued for S1 for working without a criminal record clearance. An exit interview was conducted, and this report (LIC809) (LIC809D) (LIC421BG) was discussed and provided Administrator Teresa Baddeley. Along with a copy of the Appeals Rights.the state’s words, verbatim · CDSS document, Dec 21, 2023