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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197604938
Report Date: 06/24/2022
Date Signed: 06/24/2022 01:04:16 PM

Document Has Been Signed on 06/24/2022 01:04 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ANNABELLE'S COTTAGEFACILITY NUMBER:
197604938
ADMINISTRATOR:DAISY HAILEYFACILITY TYPE:
740
ADDRESS:3732 VITRINA LANETELEPHONE:
(661) 947-0052
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 5CENSUS: 3DATE:
06/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Shela NicolasTIME COMPLETED:
01:00 PM
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LPA Spaeth conducted an unannounced visit to the facility and was greeted by caregiver. LPA was asked to record temperature and answer COVID questions. LPA observed the sign in station which contained thermometer, hand sanitizer, and sign in sheet with COVID questions. LPA also observed another caregiver who was wearing a mask.

LIving Room/Dining Room Area - LPA observed comfortable seating in the living room along with dining room furniture. The room was comfortable and clean.

Family Room/Kitchen Area - LPA observed a resident watching television in the family room and saw the room contained comfortable furniture. LPA observed there were no harmful chemicals in the cabinet beneath the sink. The medications and knives were locked in the kitchen cabinets. LPA observed the refrigerator contained a five-day supply of fresh fruits and vegetables, eggs, and other dairy products. The freezer contained frozen meats and vegetables. The sink area contained wash your hands sign, paper towels, and hand soap. The pantry was neat and well-stocked with a seven-day supply of canned goods and other dry good items.

Backyard area -LPA observed a shaded area in the backyard which contained comfortable seating. The side gate was not locked that leads from the backyard to the front yard. The backyard was also neat and clean.

Hallway area - LPA observed two hall closets which contained clean linens, an adequate supply of PPE items, and diapers.

Residents' Rooms- There are four resident rooms and three are occupied. Each room contained bed, linens, chest of drawer, closet, night lamp, night stand and a chair. Each room was neat and clean.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/24/2022
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ANNABELLE'S COTTAGE
FACILITY NUMBER: 197604938
VISIT DATE: 06/24/2022
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Locked Laundry Area - LPA observed the locked laundry area which contained laundry detergent, cleaning supplies, washer and dryer. A door within the room led to the garage which contained additional storage items and an additional refrigerator which contained eggs and frozen meats.

Bathrooms - There are two bathrooms in the facility. Both bathrooms contained wash your hands sign, hand soap, paper towels, and a trash can. The Caregiver explained one bathroom is used for showering residents; however, the bathroom did not contain a slip resistant mat.

Under Title 22 General Regulations, the following citation was issued and recorded on LIC 809D.

Exit interview was conducted, appeal rights discussed and LPA gave a copy of the report during the visit.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/24/2022 01:04 PM - It Cannot Be Edited


Created By: Melissa Spaeth On 06/24/2022 at 12:19 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ANNABELLE'S COTTAGE
FACILITY NUMBER: 197604938

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/27/2022
Section Cited

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87303 Maintenance and Operation (3) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers. This requirement is not met as evidenced by:
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LPA Spaeth observed there are no non-skid mats located in the two bathrooms, which is an immediate health and safety risk to residents in care.
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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:Cassandra Harris
LICENSING EVALUATOR NAME:Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:
DATE: 06/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2022


LIC809 (FAS) - (06/04)
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