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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197604938
Report Date: 10/06/2022
Date Signed: 10/06/2022 04:18:02 PM

Document Has Been Signed on 10/06/2022 04:18 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: 4DATE:
10/06/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Shela Nicolas TIME COMPLETED:
12:30 PM
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LPA Spaeth conducted an unannounced visit regarding Complaint #31-AS-20220405104144. LPA began tour of the facility with caregiver at 9:55 am. Upon touring the laundry room at 10:17 am, LPA observed the laundry room door was not locked. LPA observed the cleaning supplies and the laundry detergent were not securely locked in the laundry room. 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.
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.

LIC809 (FAS) - (06/04)
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Document is an Amendment of Original Document on 11/15/2022 08:24 AM


Created By: Melissa Spaeth On 10/06/2022 at 10:57 AM
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
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 B
10/06/2022
Section Cited
CCR
87705(f)

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87705Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia:
(1) Knives...(2) Over-the-counter medication, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
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This item was secured during LPA's inspection and a new battery was added to the door lock. LPA confirmed the door was locked.
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Based on observation, the licensee failed to ensure cleaning supplies (toxins) were inaccessible to dementia residents which poses an immediate health 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: 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


LIC809 (FAS) - (06/04)
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