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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197604938
Report Date: 11/15/2022
Date Signed: 11/15/2022 11:11:40 AM

Document Has Been Signed on 11/15/2022 11:11 AM - 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: DATE:
11/15/2022
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Anne GregorioTIME COMPLETED:
11:00 AM
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An Informal Conference was conducted today in the Woodland Hills Adult and Senior Care Regional Office. The purpose of this Informal Conference is to discuss a complaint regarding the allegations Resident (R1) sustained unexplained injuries while in care and resident wandered away from the facility. Prior to the meeting, Administrator was given the chance to review the facility file.

Present at today's meeting are the following:
· Anne Gregorio - Administrator
· Cassandra Harris, Licensing Program Manager (LPM)
· Melissa Spaeth, Licensing Program Analyst (LPA)

The informal conference process was explained to the Licensee. The Licensee was also informed that this Informal Conference is a part of the administrative action process. Further citations may result in a Non-Compliance Conference, which could lead to a referral to the Department's Legal Division for possible license revocation or other administrative actions.



BRIEF HISTORY: Facility has been in operation since licensure on June 30, 2004 for a maximum of five (5) residents. LPM Harris discussed and expressed concerns regarding the April 1, 2022.

A complaint investigation was conducted by Investigations Branch Investigator Christine Ferris and Heidy Bendana regarding the allegation resident sustained unexplained injuries while in care. Based upon the physician's report dated 3/16/2022 and residents' interviews, the allegation was unfounded.

On October 6, 2022, LPA Spaeth conducted a complaint investigation and interviewed the caregiver who confirmed R1 left the facility at approximately 7:30 am on 4/01/2022 and the caregiver was unaware that the resident had been absent for approximately three hours. Caregiver stated R1 had knocked on a neighbor's
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2022
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: 11/15/2022
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door and the neighbor brought R1 back to the facility at approximately 10:30 am. Therefore the allegation, resident wandered away from the facility was substantiated. During LPA’s visit, LPA observed the cleaning supplies and the laundry detergent were not securely locked in the laundry room. LPA observed the caregiver locking the items in a kitchen cabinet.

An annual was conducted on 6/24/2022 and LPA observed there were no non-skid mats located in the two bathrooms. The Administrator corrected the deficiency by forwarding snapshots of the bathrooms. Licensing Program Analysts (LPA’s) Spaeth, Avetisyan and Stamps conducted an annual on 9/30/2021 and deficiencies were issued regarding the following categories: incomplete resident files, lack of food, inoperable carbon monoxide/smoke detectors, staff first aid training, Administrator qualifications, sufficient staffing, centrally stored medication records, active corporation status, and liability insurance.

Administrator agreed to provide a new LIC 500 and updated elopement plan of care to ensure safety of the residents. Licensee will provide these reports to CCL by November 28, 2022 via email. The Licensee was informed that Community Care Licensing (CCL) shall continue to frequently monitor the facility as often as necessary to ensure the Licensee's compliance with Title 22 Regulations.

Exit interview conducted, and a copy of the report was issued to the Caregiver.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2022
LIC809 (FAS) - (06/04)
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