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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197604938
Report Date: 10/06/2022
Date Signed: 10/06/2022 04:19:19 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/05/2022 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20220405104144
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: 4DATE:
10/06/2022
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Shela NicolasTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Resident wandered away from the facility
INVESTIGATION FINDINGS:
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LPA Spaeth conducted an unannounced visit and was greeted by two caregivers. LPA's temperature was recorded and COVID questions were completed by LPA. LPA stated the purpose of the visit was to complete the investagation regarding two allegations which are resident sustained unexplained injuries while in care and resident wandered away from the facility.

LPA reviewed resident's file at 10:30 am until 10:40 am. LPA interviewed caregiver at 10:40 until 10:55 am who was working at the facility on the day that the alleged allegation occurred. During the interview, the caregiver stated was not aware that Resident (R1) had walked out of the facility on 4/01/2022 at approximately 10:30 am. Based upon LPA's interview of the caregiver, this allegation is substantiated.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, a deficiency was cited (refer to LIC 809-D).
LPA Spaeth Exit interview conducted, Appeal Rights discussed, and a copy of the signed report was given to Administrator.



Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/05/2022 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20220405104144

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: 4DATE:
10/06/2022
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Shela NicolasTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Resident sustained unexplained injuries while in care
INVESTIGATION FINDINGS:
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A complaint was received on April 5, 2022 which alleged Resident #1 (R1) sustained unexplained injuries while in care. The complaint investigation was conducted by Investigations Branch (IB) Investigator Christine Ferris and Heidy Bendana. The allegation stated R1 was found by the reporting party (RP) at RP’s front door, was dressed in only a t-shirt and diaper, and was full of bruises up and down the left arm. Investigator Christine Ferris and Investigator Heidy Bendana conducted a file review on April 18, 2022 at the facility and obtained the physician’s report dated March 16, 2022 noting R1’s primary diagnosis as confusion, failure to thrive, unable to care for self and a history of skin condition or breakdown with bruising and rashes on bilateral forearms.

Investigator Ferris and Bendana interviewed four residents, which included the resident mentioned in the complaint. R1 stated feels comfortable, safe, and likes living in the facility. R1 was asked to explain the bruises on arms; R1 stated bruises very easily and stated sustained bruises while laying down. R1 also denied being neglected, hit, grabbed, mistreated or harmed by staff. R2. R3, and R4 stated felt safe and stated other residents have not complained about staff members and had not observed any residents pulled, grabbed, hit, abused or neglected by staff in any way.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022
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 4
Control Number 31-AS-20220405104144
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/06/2022
NARRATIVE
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R1 allowed investigators to take pictures of the bruises on arms. Investigators observed the bruising was on R1’s elbows, wrists, and sporadically along forearms on both arms. The Investigators also reported the bruises on R1’s arms were not indicative of being grabbed or hit and there were no hand or finger imprints on R1’s arms. The bruises did not appear concerning and were not consistent with physical abuse.

Investigators Ferris and Bendana also interviewed staff member (S1) who stated has been working at the facility since November of 2021. S1 stated they have not witnessed or heard of any abuse or neglect in the facility.

Based on the information collected and interviews of residents and staff member, there is not sufficient evidence to substantiate the allegation. Therefore, the allegation is Unfounded. “This agency has investigated the complaint alleging “resident (R1) sustained unexplained injuries while in care.” This allegation is unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 31-AS-20220405104144
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/12/2022
Section Cited
CCR
87468(a)(2)
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Personal Rights (a) Residents in residential care facilities for the elderly shall have personal rights...(2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This was evidenced by:
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Administrator will submit a written plan as to what steps will be taken to ensure residents who are not able to leave the facility unannisted do not. Administrator will also submit a signed document which states caregivers received training from the Administrator regarding the written plan.
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The resident wandered away from the facility at about 10:30 am on 4/01/2022 and brought back to the facilty by a neighbor. Also, based upon LPA interviewing the caregiver, the resident to leave the facility without supervision 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.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4