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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607362
Report Date: 04/12/2023
Date Signed: 04/12/2023 03:56:45 PM

Document Has Been Signed on 04/12/2023 03:56 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
N LA & CEN COA AC/SC, 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: 3DATE:
04/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:49 AM
MET WITH:Maria Ana RodriguezTIME COMPLETED:
04:15 PM
NARRATIVE
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On 04/12/2023 at 9:49 a.m. Licensing Program Analyst (LPA) Evelin Rios arrived at the facility listed above to conduct an unannounced annual inspection. LPA observed appropriate Covid-19 postings on the outside of front door. LPA was greeted by Maria Ana Rodriguez the house manager and granted access. Maria Ana requested LPA check temperature on temperature reader affixed to the entry wall. Maria Ana monitored LPA's temperature and asked LPA to sign in. LPA observed staff #1 (S1) and 2 residents in the living area. LPA called the Administrator Daisy Hailey and notified Administrator reason for the visit. Administrator could not meet LPA and designated Maria Ana to sign this report.

At 10:02 a.m. LPA and Maria Ana toured the physical plant of the facility, and the following was observed.

Living room/ Dining area: The living room and dining area were clean and properly furnished. Fireplace not in use secured with a screen.
Bedrooms: LPA inspected five (5) out of five (5) resident bedrooms. One (1) out of the five (5) bedrooms is a shared bedroom. LPA observed each private resident room to be properly furnished with one bed, appropriate night stand, chair, beddings and with sufficient lighting and storage. LPA observed an air mattress and twin bed in the shared bedroom. LPA asked Maria Ana who sleeps in the air mattress and Maria Ana indicated she sometimes sleeps in the shared room occupied by one resident when she is extremely tired. S1 immediately removed the air mattress.
Bathrooms: The facility has three (3) bathrooms. LPA took water temperature from one (1) out three (3) bathrooms sink at 10:13 a.m. and temperature was 116.3 degrees Fahrenheit. LPA observed the bathrooms to be clean and properly supplied with toilet paper and trash bins with lids.
Laundry/Garage: Laundry room leading to the garage and staff bedrooms is kept locked and inaccessible to residents. Detergents are kept locked in a the laundry room.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2023
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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Document Has Been Signed on 04/12/2023 03:56 PM - It Cannot Be Edited


Created By: Evelin Rios On 04/12/2023 at 02:23 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: ANNABELLE'S COTTAGE II
FACILITY NUMBER: 197607362

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87457(c)(1)(A)
87457(c)Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.(1)The appraisal shall include, at a minimum, an evaluation of the prospective resident's functional capabilities, mental condition and an evaluation of social factors as specified in Sections 87459, Functional Capabilities and 87462 Social Factors.(A)The licensee shall be permitted to use the form LIC 603 (Rev. 6/87), Preplacement Appraisal Information, to document the appraisal.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs record review the licensee did not comply with the section cited above in two (2) out of three (3) resident's records revealed a missing preplacement appraisal information which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/21/2023
Plan of Correction
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Licensee will conduct a record review and identify resident files with incomplete or missing documentation. Licensee will send to LPA via email the LIC 603 and LIC625 for those residents missing documentation by POC date 04/21/2023.
Type B
Section Cited
HSC
1569.267
(d) The licensee shall provide initial and ongoing training for all members of its staff to ensure that residents’ rights are fully respected and implemented.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews and record review the licensee did not comply with the section cited above in two (2) out of two (2) staff interviews and records revealed staff do not have ongoing training on Resident's Bills of Rights to ensure the resident's rights are fully respected and implemented which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/21/2023
Plan of Correction
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Licensee will conduct in house training of the Resident's Bill of Rights and review Statement Acknowledging Requirement to Report Suspected Abuse of Dependent Adults and Elders document with all staff. Licensee will submitt to LPA via email a copy of the training conducted, signed and dated by staff and administrator by POC date 04/21/2023.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Eva Miller
LICENSING EVALUATOR NAME:Evelin Rios
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/12/2023 03:56 PM - It Cannot Be Edited


Created By: Evelin Rios On 04/12/2023 at 02:48 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: ANNABELLE'S COTTAGE II
FACILITY NUMBER: 197607362

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)(2)(D)
87307(a)Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply:(2)Resident bedrooms shall be provided which meet, at a minimum, the following requirements:(D)Not more than two residents shall sleep in a bedroom.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in allowing one (1) out five (5) residents bedroom to be occupied by a resident and staff in resident's shared bedroom which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/12/2023
Plan of Correction
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Staff immediately removed air mattress from resident's shared bedroom. POC cleared on todays visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Eva Miller
LICENSING EVALUATOR NAME:Evelin Rios
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2023


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ANNABELLE'S COTTAGE II
FACILITY NUMBER: 197607362
VISIT DATE: 04/12/2023
NARRATIVE
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At 10:17 a.m. LPA observed S1 test the hardwired, interconnected smoke detector located through out the facility. Detectors were observed to be functioning properly. LPA observed two carbon monoxide detector functioning properly. Maria Ana stated they have enough PPE to last more than 30 days.

Kitchen/ Dinning area: The kitchen was observed to be clean and clear of clutter. Appliances and fixtures were functioning properly. LPA observed cleaning products kept locked under the kitchen sink. LPA observed knives locked in a kitchen drawer. LPA observed a sufficient amount of 2- day perishable and 7-day non-perishable food at the facility; properly stored. On a wall leading to the kitchen LPA observed one (1) fire extinguishers fully charged with a last serviced date of 05/19/2022. Dining area had appropriate table and chairs to sit the capacity of the facility.


Medications: At 10:20 a.m. LPA observed centrally stored medications are maintained in a locked cabinet by the kitchen and living room. Medications were observed locked in the cabinet. One pharmacy is being utilized for two residents. Refills are either done automatically every 30 days, or ordered by the physician. Medication Records were reviewed for proper documentation. Medication records are maintained manually.
Surrounding Grounds: Entry and exits were free of obstruction. There is a covered patio with appropriate furniture for clients to use

At 10:30 a.m. LPA conducted interviews with three (3) out of three (3) residents and two (2) out of two (2) staff present.

At 10:55 a.m. LPA interviewed Administrator by telephone and notified Administrator an Infection Control Plan was not on file for the facility. The licensee was granted a waiver under the Authority of Governor Newsom’s Executive Order N-11-22 issued on June 17, 2022, and the administrator agreed to submit the Infection Control Plan by June 12, 2023.

Client/Staff Records: At approximately 12:15 p.m. three (3) out three (3) residents records and two (2) staff records were reviewed to insure compliance.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D). Exit Interview Conducted. Appeal rights provided. A Copy of the Report Issued.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023
LIC809 (FAS) - (06/04)
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