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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197604938
Report Date: 01/19/2024
Date Signed: 01/19/2024 03:16:27 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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
01/18/2024 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20240118140742
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:
01/19/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Anne GregorioTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Facility staff did not ensure that dangerous items were inaccessible to the residents.
INVESTIGATION FINDINGS:
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On 01/19/2024 Licensing Program Analyst (LPA) Melissa Spaeth, initiated a complaint investigation for the allegation(s) listed above. LPA Spaeth was greeted by the caregiver. LPA spoke to the Licensee via phone and LPA Spaeth explained the purpose of the visit was to investigate a complaint. LPA and the caregiver began a tour at 10:20 am until 11 am. At 10:20 am, LPA observed the kitchen knives were locked in a drawer.
It was alleged that the laundry room was unlocked and contained laundry detergents. At 10:35 am, LPA observed the laundry room was unlocked and contained cleaning solutions and laundry detergents which was accessible to residents. At 10:40 am, LPA observed a four-prong grilling utensil was lying next to the grill in the backyard and was not locked in a secure location. Based upon LPA Spaeth’s observations, the allegation facility staff did not ensure that dangerous items were inaccessible to the residents is substantiated. Per CA Code of Regulations, Title 22, the following deficiency is issued (See 9099-D).

Exit interview conducted, appeal rights discussed, and a copy of the report was given.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2024
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 3
Control Number 31-AS-20240118140742
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: ANNABELLE'S COTTAGE
FACILITY NUMBER: 197604938
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/19/2024
Section Cited
CCR
87705(f)(1)
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87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (1) Knives…tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
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Staff immediately removed the grilling utensil and locked the utensil in the garage. Staff also immediately locked the laundry room.

The deficiency was cleared during LPA's visit.
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Based on LPA's observations, a four-prong grilling utensil was beside the outdoor grill, was not locked & the laundry room was not locked & contained laundry soap & cleaning solutions. This poses an immediate health & safety risk to the 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: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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
01/18/2024 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20240118140742

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:
01/19/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Anne GregorioTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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9
Facility staff did not ensure that medications were properly stored.
INVESTIGATION FINDINGS:
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It was alleged that residents’ medications were not locked. During LPA’s tour of the facility, LPA observed the caregiver unlocked a kitchen cabinet at 10:20 am which contained the residents’ medications. LPA also toured the entire facility including common areas, the two bathrooms, and the residents’ rooms. LPA did not observe medications located within any of these locations. Therefore, the allegation, facility staff did not ensure that medications were properly stored is unsubstantiated.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3