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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197604938
Report Date: 03/08/2023
Date Signed: 03/08/2023 12:52:51 PM

Document Has Been Signed on 03/08/2023 12:52 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:
03/08/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Shela Nicolas TIME COMPLETED:
01:00 PM
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LPA Spaeth conducted an unannounced visit and stated the purpose of the visit was to conduct a case management visit to tour the facility. LPA was greeted by caregiver. LPA observed two caregivers working at the facility and observed both were wearing masks.

LPA and caregiver began the tour at 12:10 pm until 12:35 pm. LPA observed the living room contained comfortable furniture. Upon walking into the kitchen/family room, LPA observed a resident listening to music in the family room.

Kitchen area - LPA observed the knives and medications were locked in kitchen cabinets. The facility contained a seven-day supply of canned goods and a two-day supply of perishable food items. A fire extinguisher was located in the kitchen.

Resident Bedrooms - LPA observed three residents in their rooms. The rooms were clean and were furnished with the appropriate furnishings.

Bathrooms - LPA observed the bathrooms contained grab bars, slip resistant mats, hand soap, paper towels, and trash cans with fitted lids.

Laundry room - LPA observed the laundry room was locked and contained laundry soap and cleaning solutions.

There are no deficiencies to report at this time. Exit interview was conducted and a copy of the report was given to the caregiver.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2023
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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