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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197604938
Report Date: 10/31/2024
Date Signed: 10/31/2024 03:28:24 PM

Document Has Been Signed on 10/31/2024 03:28 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ANNABELLE'S COTTAGEFACILITY NUMBER:
197604938
ADMINISTRATOR/
DIRECTOR:		DAISY HAILEYFACILITY TYPE:
740
ADDRESS:3732 VITRINA LANETELEPHONE:
(661) 947-0052
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 5CENSUS: 3DATE:
10/31/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Vilma GreshamTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced case management visit and was greeted by the caregiver. The caregiver confirmed there are three residents living in the facility.

LPA Spaeth and the Caregiver toured the facility at 1:45 pm until 2:10 pm. LPA observed the following:

Kitchen - LPA observed the knives were locked in the kitchen drawer. The medications were locked in a cabinet. There is a two-day supply of perishable food and a seven-day supply of non-perishable foods.

Bathroom - The bathroom was clean and contained hand soap, paper towels, slip resistant mat, grab bars, and a trash can.

Resident Rooms - LPA Spaeth observed the rooms were neat and clean.

There are no deficiencies to report at this time. Exit interview conducted and a copy of the report was given.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 10/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2024
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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