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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197604938
Report Date: 01/23/2025
Date Signed: 01/23/2025 03:16:33 PM

Document Has Been Signed on 01/23/2025 03:16 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: 2DATE:
01/23/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:36 PM
MET WITH:Vilma GreshamTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced case management visit and was greeted by a staff member and a resident. The caregivers LPA stated the purpose of the visit was to tour the facility. The caregiver confirmed there are two residents living in the facility.

LPA Spaeth and the staff member toured the facility at 1:50 pm until 2:15 pm. LPA observed the following:

Living Room and Family Room - LPA observed comfortable seating in both rooms.

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.

Laundry Room/Garage- The door leading to the laundry room & garage were locked.

LPA observed the facility was 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: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2025
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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