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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607362
Report Date: 03/04/2022
Date Signed: 03/04/2022 12:38:50 PM

Document Has Been Signed on 03/04/2022 12:38 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 COTTAGE IIFACILITY NUMBER:
197607362
ADMINISTRATOR:DAISY HAILEYFACILITY TYPE:
740
ADDRESS:6218 W. AVENUE J-12TELEPHONE:
(661) 579-9522
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 6CENSUS: 4DATE:
03/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Mary Ana Rodriguez - StaffTIME COMPLETED:
12:50 PM
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At 11:40 a.m., Licensing Program Analyst (LPA) Melissa Ruiz conducted an unannounced annual inspection at the facility mentioned above. LPA was greeted by staff, Mary Ana Rodriguez. This is a 6-bedroom, 3-bathroom single story residential care facility for the elderly. A physical tour was initiated at 12:00 p.m. and observed the following:

Infection control: One infection control sign was observed outside the facility. LPA reminded Administrator to place additional covid-19 signage outside the entrance. Upon entering the location, LPA observed the sign in station which contained thermometer, hand sanitizer, and visitors sign in sheet. LPA's temperature was recorded. Sufficient PPE supplies were observed. Food Inspection: LPA observed there to be sufficient stock of one-week non-perishable foods and two-day perishable foods. Food storage and preparation areas are clean and inaccessible to pests. Sharps and cleaning supplies are centrally stored in locked cabinets in the kitchen. Smoke detectors/carbon monoxide were located throughout the facility. Medications are centrally stored in a cabinet near the kitche and are kept locked at times. Resident rooms: LPA was then escorted through the home and observed the resident’s rooms were properly furnished. Bathrooms: LPA observed the bathroom which contained wash your paper towels, hand sanitizer, and trash cans with closed tight-fitting lids. The water temperature read 120 degrees Fahrenheit. Outside areas: LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There are no bodies of water. Administrator was unavailable at the time of the visit and staff Mary Ana Rodriguez signed the report.

No deficiencies cited. An exit interview was conducted. A copy of this report was signed and provided.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE: DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2022
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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